Fillable Form 8840 - Closer Connection Exception Statement For Aliens

Form 8840 - Closer Connection Exception Statement For Aliens - 2013 Page 2

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Form 8840 (2013)

Page

Part IV

Significant Contacts With Foreign Country or Countries in 2013

Where was your regular or principal permanent home located during 2013 (see instructions)?

If you had more than one permanent home available to you at all times during 2013, list the location of each and

explain

▶

Where was your family located?

Where was your automobile(s) located?

Where was your automobile(s) registered?

Where were your personal belongings, furniture, etc., located?

Where was the bank(s) with which you conducted your routine personal banking activities located?

Yes

Did you conduct business activities in a location other than your tax home? .

If “Yes,” where?

22a Where was your driver’s license issued?

b If you hold a second driver’s license, where was it issued?

Where were you registered to vote?

When completing official documents, forms, etc., what country do you list as your residence?

Have you ever completed:

a Form W-8BEN or any other W-8 form (relating to foreign status)?

Yes

b Form W-9, Request for Taxpayer Identification Number and Certification?

Yes

c Form 1078, Certificate of Alien Claiming Residence in the United States? .

Yes

d Any other U.S. official forms? If “Yes,” indicate the form(s)

Yes

▶

In what country or countries did you keep your personal, financial, and legal documents?

From what country or countries did you derive the majority of your 2013 income?

Yes

Did you have any income from U.S. sources? .

If “Yes,” what type?

In what country or countries were your investments located (see instructions)?

Yes

Did you qualify for any type of “national” health plan sponsored by a foreign government? .

If “Yes,” in what country?

If “No,” please explain

▶

If you have any other information to substantiate your closer connection to a country other than the United States or you wish

to explain in more detail any of your responses to lines 14 through 30, attach a statement to this form.

Sign here

Under penalties of perjury, I declare that I have examined this form and the accompanying attachments, and to the best of my knowledge and belief, they

only if you

are true, correct, and complete.

are filing

this form by

itself and

not with

your U.S.

tax return

Your signature

Date

8840

Form