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Country of Residence *

Estimated Worldwide Income (USD) *

Investment Income Types (check all that apply)

Dividends / Interest Rental Income Capital Gains / Losses Other

Do you have foreign financial accounts (bank, brokerage, mutual funds, and certain pensions) with a combined balance exceeding $10,000 at any point during the year? (FBAR) *

Yes No

Form 8938 — Specified Foreign Financial Assets *

Did the total combined value of your specified foreign financial assets (non-U.S. bank/investment accounts, etc.) ever exceed any of these thresholds during the tax year(s) being filed?
(Approximate USD; double amounts if filing jointly)

If living in the U.S.: More than $50,000 on Dec 31 or $75,000 at any time
If living abroad (tax home abroad + bona fide residence or 330-day test): More than $200,000 on Dec 31 or $300,000 at any time

Yes No

Where did you live during the tax year(s) being filed? (city and country)

Are you self-employed or a sole proprietor? *

Yes No

Do you have any partnership interests / K-1s? *

Yes No

Are you a director or shareholder of a foreign company or trust? *

Yes No

Have you received any IRS notices or are you under audit? *

Yes No

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