Free Form 8802 (Rev. April 2007) - Federal

Form (Rev. April 2007)

8802

Application for United States Residency Certification
See separate instructions Foreign claim form attached

OMB No. 1545-1817

Department of the Treasury Internal Revenue Service

Additional request (see instructions) Electronic payment confirmation no. Applicant's name

Applicant's U.S. taxpayer identification number

If a joint return was filed, spouse's name (see instructions)

If a joint return was filed, spouse's U.S. taxpayer identification number

If a separate certification is needed for spouse, check here 1 Applicant's name and taxpayer identification number as it should appear on the certification if different from above

2

Applicant's address during the calendar year for which certification is requested, including country and ZIP or postal code (see instructions)

3a Mail Form 6166 to the following address:

b Appointee Information (see instructions):
Appointee Name ( Phone No.

)

CAF No. Fax No.

(

)

4 a

Applicant is (check appropriate box(es)): Individual. Check all applicable boxes. U.S. citizen U.S. lawful permanent resident (green card holder) Sole proprietor Other U.S. resident alien. Type of entry visa Current nonimmigrant status and date of change (see instructions) Dual-status U.S. resident (see instructions). From to Partial-year Form 2555 filer (see instructions). U.S. resident from to Partnership. Check all applicable boxes. U.S. Foreign LLC Trust. Check if: Grantor (U.S.) Simple Rev. Rul. 81-100 Trust IRA (for Individual) Grantor (foreign) Complex Section 584 IRA (for Financial Institution) Estate Corporation. If incorporated in the United States only, go to line 5. Otherwise, continue. Check if: Section 269B Section 943(e)(1) Section 953(d) Section 1504(d) Country or countries of incorporation If a dual-resident corporation, specify other country of residence If included on a consolidated return, attach page 1 of Form 1120 and Form 851. S corporation Employee benefit plan/trust. Plan number, if applicable Check if: Section 401(a) Section 403(b) Section 457(b) Exempt organization. If organized in the United States, check all applicable boxes. Section 501(c) Section 501(c)(3) Governmental entity Indian tribe Other (specify) Disregarded entity. Check if: LLC LP LLP Other (specify) Nominee applicant (must specify the type of entity/individual for whom the nominee is acting)
Cat. No. 10003D Form

b c d e

f g h

i j

For Privacy Act and Paperwork Reduction Act Notice, see instructions.

8802

(Rev. 4-2007)

Form 8802 (Rev. 4-2007)

Page

2

Applicant name: 5
Was the applicant required to file a U.S. tax form for the tax period(s) on which certification will be based? Yes. Check the appropriate box for the form filed and go to line 7. 990 990-T 1040 1041 1065 1120 1120S 3520-A Other (specify) No. Attach explanation (see instructions). Check applicable box and go to line 6. Minor child QSub U.S. DRE Foreign DRE FASIT Foreign partnership Other

5227

5500

Section 761(a) election

6

Was the applicant's parent, parent organization or owner required to file a U.S. tax form? (Complete this line only if you checked "No" on line 5.) Yes. Check the appropriate box for the form filed by the parent. 990 990-T 1040 1041 1065 Other (specify) Parent's/owner's name and address 1120 1120S 5500

7

and U.S. taxpayer identification number No. Attach explanation (see instructions). Calendar year(s) for which certification is requested. If certification is for the current calendar year, a penalties of perjury statement is required (see instructions). Tax period(s) on which certification will be based (see instructions) Purpose of certification. Must check applicable box. Income tax Other (must specify) VAT (specify NAICS codes)

8 9

10

This space can be used to enter additional required information

Sign here
Keep a copy for your records.

Under penalties of perjury, I declare that I have examined this application and accompanying attachments, and to the best of my knowledge and belief, they are true, correct, and complete. If I have designated a third party to receive the residency certification(s), I declare that the certification(s) will be used only for obtaining information or assistance from that person relating to matters designated on line 9. Applicant's signature (or individual authorized to sign for the applicant) Applicant's daytime phone no.:

Signature Name and title (print or type)

Date

Spouse's signature. If a joint application, both must sign.

Name (print or type) Form

8802

(Rev. 4-2007)

Form 8802 (Rev. 4-2007) Applicant Name

User Fee Voucher for U.S. Residency Certification Application
Applicant TIN

Page

3

For IRS use only: Pmt Amt $ Date Pmt Verified: / /

Appointee Name (If Applicable)

Calendar year(s) for which certification is requested (must be the same year(s) indicated on line 7)

11

Enter the number of certifications needed in the column to the right of each country for which certification is requested. Column A Column B Column C Column D

Country
Armenia

CC
AM

#

Country
France Georgia

CC
FR GG

#

Country
Lithuania Luxembourg

CC
LH LU MX

#

Country
Spain

CC
SP

#

Australia

AS

Sri Lanka

CE

Austria

AU

Germany

GM

Mexico

Sweden

SW

Azerbaijan

AJ

Greece

GR

Moldova Morocco

MD MO

Switzerland

SZ

Bangladesh

BG

Hungary

HU

Tajikistan

TI

Barbados

BB

Iceland India Indonesia

IC

Netherlands

NL

Thailand

TH

Belarus

BO

IN ID

New Zealand

NZ

Trinidad and Tobago Tunisia

TD TS

Belgium

BE

Norway Pakistan

NO

Bermuda

BD

Ireland

EL

PK

Turkey

TU

Canada

CA

Israel

IS

Philippines

RP

Turkmenistan

TX

China

CH

Italy

IT

Poland

PL PO

Ukraine

UP

Cyprus

CY

Jamaica

JM

Portugal

United Kingdom

UK

Czech Republic

EZ

Japan

JA KZ KS

Romania

RO

Uzbekistan

UZ

Denmark

DA

Kazakhstan

Russia

RS

Venezuela

VE

Egypt Estonia

EG EN

Korea, South Kyrgyzstan

Slovak Republic

LO

KG

Slovenia

SI

Finland

FI

Latvia

LG

South Africa

SF

Column A - Total
Number of Forms 6166
1 - 20 21 - 40 41 - 60 61 - 80 81 - 100

Column B - Total
Number of Forms 6166
101 - 120 121 - 140 141 - 160 161 - 180 181 - 200

Column C - Total

Column D - Total

User Fee
$ 35.00 $ 40.00 $ 45.00 $ 50.00 $ 55.00

User Fee
$ 60.00 $ 65.00 $ 70.00 $ 75.00 $ 80.00

12a Enter the total number of certifications requested (add columns A, B, C, and D of line 11) b If the total number of certifications is 20 or less, go to line 13 c If the total on line a is greater than 20, enter $5 for each additional 20 certifications (see instructions) 13 Amount owed. Add lines 12b and 12c
Form

12a 12b $35

12c 13

8802

(Rev. 4-2007)