
Form 1040NR
Department of the Treasury
Internal Revenue Service
U.S. Nonresident Alien Income Tax Return
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Information about Form 1040NR and its separate instructions is at www.irs.gov/form1040nr.
For the year January 1–December 31, 2016, or other tax year
beginning, 2016, and ending , 20
OMB No. 1545-0074
2016
Please print
or type
Your first name and initialLast nameIdentifying number (see instructions)
Present home address (number, street, and apt. no., or rural route). If you have a P.O. box, see instructions.
Check if:
Individual
Estate or Trust
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions).
Foreign country name Foreign province/state/county Foreign postal code
Filing
Status
Check only
one box.
1
Single resident of Canada or Mexico or single U.S. national
2
Other single nonresident alien
3
Married resident of Canada or Mexico or married U.S. national
4
Married resident of South Korea
5
Other married nonresident alien
6
Qualifying widow(er) with dependent child (see instructions)
If you checked box 3 or 4 above, enter the information below.
(i) Spouse’s first name and initial(ii) Spouse’s last name(iii) Spouse’s identifying number
Exemptions
If more
than four
dependents,
see instructions.
7 a
Yourself. If someone can claim you as a dependent, do not check box 7a ....
b
Spouse.Check box 7b only if you checked box 3 or 4 above andyour spouse did not
have any U.S. gross income ...................
}
Boxes checked
on 7a and 7b
c
Dependents: (see instructions)
(1) First name Last name
(2) Dependent’s
identifying number
(3) Dependent’s
relationshipto you
(4)✔if qualifying
child for child tax
credit (see instr.)
No. of children
on 7c who:
• lived with you
• did not live with
you due to divorce
or separation (see
instructions)
Dependents on 7c
not entered above
dTotal number of exemptions claimed .................
Add numbers on
lines above
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Income
Effectively
Connected
With U.S.
Trade/
Business
Attach Form(s)
W-2, 1042-S,
SSA-1042S,
RRB-1042S,
and 8288-A
here. Also
attach Form(s)
1099-R if tax
was withheld.
8Wages, salaries, tips, etc. Attach Form(s) W-2 ..............8
9a Taxable interest ........................9a
bTax-exempt interest. Do not include on line 9a .....9b
10a Ordinary dividends .......................10a
bQualified dividends (see instructions) ........10b
11Taxable refunds, credits, or offsets of state and local income taxes (see instructions) ..11
12
Scholarship and fellowship grants. Attach Form(s) 1042-S or required statement (see instructions)
12
13Business income or (loss). Attach Schedule C or C-EZ (Form 1040) ........13
14
Capital gain or (loss). Attach Schedule D (Form 1040) if required. If not required, check here
14
15Other gains or (losses). Attach Form 4797 ................15
16a IRA distributions ..16a16b
Taxable amount (see instructions)
16b
17a Pensions and annuities17a17b
Taxable amount (see instructions)
17b
18Rental real estate, royalties, partnerships, trusts, etc. Attach Schedule E (Form 1040) ..18
19Farm income or (loss). Attach Schedule F (Form 1040) ............19
20Unemployment compensation ...................20
21Other income. List type and amount (see instructions)21
22
Total income exempt by a treaty from page 5, Schedule OI, Item L (1)(e)
22
23 Combine the amounts in the far right column for lines 8 through 21. This is your total
effectively connected income..................
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23
Adjusted
Gross
Income
24Educator expenses (see instructions) ........24
25Health savings account deduction. Attach Form 8889 ...25
26Moving expenses. Attach Form 3903 ........26
27
Deductible part of self-employment tax. Attach Schedule SE (Form 1040)
27
28Self-employed SEP, SIMPLE, and qualified plans ....28
29Self-employed health insurance deduction (see instructions)29
30Penalty on early withdrawal of savings ........30
31Scholarship and fellowship grants excluded ......31
32IRA deduction (see instructions) ..........32
33Student loan interest deduction (see instructions) ....33
34Domestic production activities deduction. Attach Form 8903 .34
35Add lines 24 through 34 .....................35
36Subtract line 35 from line 23. This is your adjusted gross income .......
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36
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see instructions.Cat. No. 11364D
Form 1040NR (2016)