Fillable Printable Form 8802
Fillable Printable Form 8802
Form 8802
Form 8802
(Rev. April 2012)
Department of the Treasury
Internal Revenue Service
Application for United States
Residency Certification
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See separate instructions.
OMB No. 1545-1817
Important. For applications filed after March 31, 2012, the user fee is $85 per application.
For IRS use only:
Additional request (see instructions) Foreign claim form attached
Pmt Amt $ .
Deposit Date: / /
Date Pmt Vrfd: / /
Electronic payment confirmation no.
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Applicant’s name Applicant’s U.S. taxpayer identification number
If a joint return was filed, spouse’s name (see instructions)
If a separate certification is needed for spouse, check here
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If a joint return was filed, spouse’s U.S. taxpayer
identification number
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. If a P.O.
box, see instructions.
3a
Mail Form 6166 to the following address:
b
Appointee Information (see instructions):
Appointee Name
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CAF No.
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Phone No.
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( )
Fax No.
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( )
4
Applicant is (check appropriate box(es)):
a
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
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Current nonimmigrant status
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and date of change (see instructions)
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Dual-status U.S. resident (see instructions). From
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to
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Partial-year Form 2555 filer (see instructions). U.S. resident from
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to
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b
Partnership. Check all applicable boxes. U.S. Foreign LLC
c
Trust. Check if: Grantor (U.S.)
Simple Rev. Rul. 81-100 Trust
IRA (for Individual)
Grantor (foreign) Complex Section 584 IRA (for Financial Institution)
d
Estate
e
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
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If a dual-resident corporation, specify other country of residence
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If included on a consolidated return, attach page 1 of Form 1120 and Form 851.
f
S corporation
g
Employee benefit plan/trust. Plan number, if applicable
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Check if: Section 401(a) Section 403(b)
Section 457(b)
h
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)
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i
Disregarded entity. Check if: LLC LP LLP Other (specify)
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j
Nominee applicant (must specify the type of entity/individual for whom the nominee is acting)
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For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 10003D
Form 8802 (Rev. 4-2012)
Form 8802 (Rev. 4-2012)
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 5227 5500
Other (specify)
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No. Attach explanation (see instructions). Check applicable box and go to line 6.
Minor child QSub U.S. DRE Foreign DRE Section 761(a) election
FASIT Foreign partnership Other
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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 1120 1120S 5500
Other (specify)
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Parent’s/owner’s name and address
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and U.S. taxpayer identification number
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No. Attach explanation (see instructions).
7 Calendar year(s) for which certification is requested.
Note. If certification is for the current calendar year or a year for which a tax return is not yet required to be filed, a penalties
of perjury statement from Table 2 of the instructions must be entered on line 10 or attached to Form 8802 (see instructions).
8
Tax period(s) on which certification will be based (see instructions).
9 Purpose of certification. Must check applicable box (see instructions).
Income tax VAT (specify NAICS codes)
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Other (must specify)
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10
Enter penalties of perjury statements and any additional required information here (see instructions).
Sign
here
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.
Keep a
copy for
your
records.
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Applicant’s signature (or individual authorized to sign for the applicant)
Signature
Date
Applicant’s daytime phone no.:
Name and title (print or type)
Spouse’s signature. If a joint application, both must sign.
Name (print or type)
Form 8802 (Rev. 4-2012)
Form 8802 (Rev. 4-2012)
Worksheet for U.S. Residency Certification Application
Page 3
Applicant Name Applicant TIN
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.
Note. If you are requesting certifications for more than one calendar year per country, enter the total number of certifications for all years for
each country (see instructions).
Column A
Country CC #
Armenia AM
Australia AS
Austria AU
Azerbaijan AJ
Bangladesh BG
Barbados BB
Belarus BO
Belgium BE
Bermuda BD
Bulgaria BU
Canada CA
China CH
Cyprus CY
Czech Republic EZ
Denmark DA
Egypt EG
Estonia EN
Column A - Total
Column B
Country CC #
Finland FI
France FR
Georgia GG
Germany GM
Greece GR
Hungary HU
Iceland IC
India IN
Indonesia ID
Ireland EI
Israel IS
Italy IT
Jamaica JM
Japan JA
Kazakhstan KZ
Korea, South KS
Kyrgyzstan KG
Column B - Total
Column C
Country CC #
Latvia LG
Lithuania LH
Luxembourg LU
Mexico MX
Moldova MD
Morocco MO
Netherlands NL
New Zealand NZ
Norway NO
Pakistan PK
Philippines RP
Poland PL
Portugal PO
Romania RO
Russia RS
Slovak Republic LO
Slovenia SI
Column C - Total
Column D
Country CC #
South Africa SF
Spain SP
Sri Lanka CE
Sweden SW
Switzerland SZ
Tajikistan TI
Thailand TH
Trinidad and Tobago TD
Tunisia TS
Turkey TU
Turkmenistan TX
Ukraine UP
United Kingdom UK
Uzbekistan UZ
Venezuela VE
Column D - Total
12 Enter the total number of certifications requested (add columns A, B, C, and D of line 11) . . . . . . . . . .
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Form 8802 (Rev. 4-2012)
