Free 2009 Form 1040-C - Federal

Form

1040-C

U.S. Departing Alien Income Tax Return
For tax period or year beginning See separate instructions. , 2009, and ending File original and one copy.
Last name

OMB No. 1545-0086

,

Department of the Treasury Internal Revenue Service

2009

Your first name and initial

Your identifying number

Print or type

If a joint return, spouse's first name and initial (see instructions)

Last name

Spouse's identifying number

U.S. address (number, street, and apt. no. or rural route)

Passport or alien registration card number Your number Spouse's number

Original date of your entry into the U.S.

City, state, and ZIP code

Date of departure

Complete foreign address

Date on which you last arrived in the U.S.

Of what country are you a citizen or subject?

Of what country are you a resident?

Caution: Form 1040-C is not a final income tax return. You must file a final return on the correct form after your tax year ends. See Final Return Required on page 2 of the instructions.

Part I
1

Explanation of Status--Resident or Nonresident Alien

Check the applicable box or boxes. Note: A nonresident alien who has income from U.S. real property may elect to treat this income as effectively connected income. Gain or loss on the disposition of a U.S. real property interest by a nonresident alien is effectively connected income or loss. For details, see the 2008 Form 1040NR instructions or Pub. 519, U.S. Tax Guide for Aliens. Group I--Resident alien. Group II--Nonresident alien with income effectively connected with a U.S. trade or business. Group III--Nonresident alien with income not effectively connected with a U.S. trade or business. Type of trade or business or occupation in the United States Visa number and class under which you were last admitted to the United States Do you have a permit to reenter the United States? If "Yes," enter the expiration date Have you signed a waiver of rights, privileges, exemptions, and immunities as described under Exceptions on page 2 of the instructions? If "Yes," enter the date signed

2 3 4 5

Yes

No

Yes

No

During your stay in the United States did you furnish either of the following forms to a withholding agent: Form W-9, Request for Taxpayer Identification Number and Certification, or Form 1078, Certificate of Alien Claiming Residence in the United States? 7a Have you applied for U.S. citizenship?

6

Yes Yes

No No

b Have you applied for, or taken other affirmative steps to apply for, lawful permanent resident status in the United States, or do you have an application pending to change your status to that of a lawful permanent Yes No resident of the United States? 8 If you filed income tax returns in the United States, give the following information for 2008: a Type of return filed (for example, Form 1040, 1040NR, etc.) b Your U.S. address shown on return d Tax paid $ c Taxable income reported $ e Balance due $ 9 Do you know of any current charges against you concerning your U.S. taxes for any tax period? Yes No 10 Do you plan to return to the United States? Yes No If "Yes," complete lines 11 through 13 below. 11 Are your spouse and any children remaining in the United States? Yes No 12 Show the approximate value and location in the United States of any property held by you: Value Location $ ; a Real property $ ; $ ; b Stocks and bonds $ ; c Cash $ ; d Other (specify) 13 If you will not return before the due date for filing a final U.S. income tax return for the current year or the due date for filing a final U.S. income tax return for the preceding year, what arrangements have you made to file the final income tax return(s) and pay the tax(es)?

For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see page 7 of instructions.

Cat. No. 11310F

Form

1040-C

(2009)

Form 1040-C (2009)

Page

2

Part II

Exemptions

Group I -- If you are a resident alien, you may claim the same exemptions allowed U.S. citizens on Form 1040. Group II -- If you are a nonresident alien with income effectively connected with a U.S. business, you may claim one exemption. Residents of Canada, India, Mexico, or the Republic of Korea (South Korea), or U.S. nationals, see page 4 of the instructions. Group III -- If you are a nonresident alien with income not effectively connected with a U.S. business, do not claim any exemptions for that income.
14a Yourself b Spouse Caution: If your parent (or someone else) can claim you as a dependent on his or her 2009 tax return, do not check box 14a. c Dependents:
(1) First name Last name (2) Dependent's SSN or ITIN (3) Dependent's relationship to you (4) if qualifying child for child tax credit No. of boxes checked on 14a and 14b . . . No. of your children on 14c who: lived with you . did not live with you due to divorce or separation . . Dependents on 14c not entered above

d Total number of exemptions claimed

Add numbers entered on lines above

Part III
15 16 17 18 19 20 21 22
Groups I and II

Figuring Your Income Tax
Total income (from page 3, Schedule A, line 4, column (d) or (e)) Adjustments. See page 4 of the instructions and attach appropriate form or statement Adjusted gross income. Subtract line 16 from line 15 Enter the amount from page 4, Schedule D, line 8 or 16, whichever applies Credits. See page 4 of the instructions and attach appropriate form or statement Subtract line 19 from line 18. If zero or less, enter -0Other taxes. See page 4 of the instructions and attach appropriate form Tax for Group I or II. Add lines 20 and 21 15 16 17 18 19 20 21 22

Group III

23 23 Total income (from page 3, Schedule A, line 4, column (f)) 24 Tax (30% of line 23). If less than 30%, attach statement showing computation 25 Total tax. Add lines 22 and 24 Note: Your tax liability on your final return may be different from line 25. 26 U.S. income tax paid or withheld at source (from page 3, Schedule A, 26 lines 4 and 5, column (c)) 27 27 Estimated U.S. income tax paid 28 28 Other payments (specify) 29 Total payments. Add lines 26 through 28 30 If line 25 is more than line 29, subtract line 29 from line 25. This is the amount you owe 31 If line 29 is more than line 25, subtract line 25 from line 29. This is the amount you overpaid. Any overpayment of tax will be refunded only when you file your final return for the tax year

24 25

Tax Summary

29 30 31

Sign Here
Keep a copy of this return for your records.

Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge. Your signature Date Date Spouse's signature (If filing jointly, both must sign even if only one had income.) Date Preparer's SSN or PTIN Check if self-employed EIN Phone no.

(A return made by an agent must be accompanied by a power of attorney.) Preparer's signature Firm's name (or yours if self-employed), address, and ZIP code

Paid Preparer's Use Only

(

)

Certificate of Compliance
This certifies that the above individual(s) has satisfied all the requirements of the Internal Revenue Code and the Internal Revenue Regulations relating to departing aliens according to all information available to me at this date. This certificate is effective for the tax period beginning , 2009, and ending , , or the tax year ended , .

(Field Assistance Area Director) Internal Revenue Service Date , By (Name) (Title) Form

1040-C

(2009)

Form 1040-C (2009)

Page

3

Schedule A
1

Income (see instructions)
(b) Type of income (such as salary, wages, taxable interest, dividends, rents, alimony received, etc.) (c) Amount of U.S. income tax paid or withheld at source Nonresident alien income (d) Resident alien income (e) Effectively (f) Not effectively connected with a U.S. connected with a U.S. trade or business trade or business

(a) Payer of income

2 3 4 5

Net gain, if any, from Schedule D (Form 1040) Net gain, if any, from Schedule B, line 2 Totals Exempt income. Do not include on line 4

2 3 4 5

Schedule B
1

Certain Gains and Losses From Sales or Exchanges of Nonresidents' Property Not Effectively Connected With a U.S. Trade or Business (see instructions). Include any U.S. income tax that was paid or withheld on these sales or exchanges on Schedule A, line 3, column (c).
(b) Date acquired (mo., day, yr.) (c) Date sold (mo., day, yr.) (d) Sales price (e) Cost or other basis (f) Gain or (loss) subtract (e) from (d)

(a) Description of property (If necessary, attach statement of descriptive details not shown below.)

2

Net gain. Combine the gains and losses entered on line 1, column (f). If the total is greater than zero, enter this net gain amount on Schedule A, line 3, column (f)

2

Schedule C

Itemized Deductions

If you are a resident alien reporting income on Schedule A, column (d), you may claim the same deductions allowable on Schedule A (Form 1040). If you are a nonresident alien reporting income on Schedule A, column (e), you may claim only deductions that are connected to U.S. trade or business income and not deducted elsewhere. See Schedule A (Form 1040NR). However, casualty or theft losses and charitable contributions do not have to be related to U.S. trade or business income. You should file Form 4684, Casualties and Thefts, to support casualty or theft losses shown below. If you are a nonresident alien reporting income on Schedule A, column (f), do not claim any deductions related to that income. 1
(a) Type of deduction (such as interest, taxes, contributions, etc.) (b) Amount of deduction (c) Type of deduction (such as interest, taxes, contributions, etc.) (d) Amount of deduction

2

Total itemized deductions. Add the amounts in columns (b) and (d) of line 1. Enter the total here and on Schedule D, line 2 or line 10, whichever applies. Exception. If the amount on Form 1040-C, line 17, is over $166,800 ($83,400 if married filing separately), see the worksheet on page 6 for the amount to enter

2
Form

1040-C

(2009)

Form 1040-C (2009)

Page

4

Schedule D

Tax Computation

Tax for Resident Alien--Group I Only (For description of groups, see line 1 on page 1.)

1 2

Enter amount from line 17 on page 2 If you itemize deductions, enter amount from page 3, Schedule C, line 2 (to the extent they are allowable on Schedule A (Form 1040)). If you do not plan to itemize deductions, enter your standard deduction. See Standard Deduction (Group I only) on page 7 of the instructions Subtract line 2 from line 1 Exemptions. If line 1 above is $125,100 or less, multiply $3,650 by the total number of exemptions claimed on line 14d on page 2. If line 1 above is over $125,100, or you provided housing to a Midwestern displaced individual, see the instructions on page 7 for the amount to enter Taxable income. Subtract line 4 from line 3 Tax. Figure your tax on the amount on line 5 by using the 2009 Tax Rate Schedules on page 10 of the instructions. Include in the total any tax from Form 4972 and Form 8814. Enter the tax here Alternative minimum tax (AMT). Enter the amount, if any, of AMT from Form 6251 Add lines 6 and 7. Enter the result here and on Form 1040-C, line 18

1

2 3

3 4

4 5

5 6

6 7 8

7 8

Tax for Nonresident Alien With Income Effectively Connected With a U.S. Trade or Business --Group II Only

9 10

Enter amount from line 17 on page 2 Enter itemized deductions from page 3, Schedule C, line 2 (to the extent they are allowable on Schedule A (Form 1040NR)) Subtract line 10 from line 9 Exemptions. If line 9 above is $125,100 or less, multiply $3,650 by the total number of exemptions claimed on line 14d on page 2. If line 9 above is over $125,100, or you provided housing to a Midwestern displaced individual, see the instructions on page 7 for the amount to enter Taxable income. Subtract line 12 from line 11 Tax. Figure your tax on the amount on line 13 by using the 2009 Tax Rate Schedules on page 10 of the instructions. Include in the total any tax from Form 4972 and Form 8814. Enter the tax here Alternative minimum tax (AMT). Enter the amount, if any, of AMT from Form 6251 Add lines 14 and 15. Enter the result here and on Form 1040-C, line 18

9

10 11

11 12

12 13

13 14

15 16

14 15 16
Form

1040-C

(2009)