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Form 8802 (Rev. October 2009) - yoshimura-sr.com

Userid:NEDICK00 DTD noticeLeadpct: 0%Pt. size: to PrintPAGER/XMLF ileid:..qbb\documents\2011 Corporate Products\ form 8802\ (Init. & date)Page 1 of 1 Changes to Telephone Numbers, Fax Numbers, and Addresses in the Instructions for form 8802(Rev. October 2009 )9:46 - 24-FEB-2011 The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before of the TreasuryInternal Revenue ServiceNotice1417(February 2011)Changes to Telephone Numbers, Fax Numbers, andAddresses in the Instructions for form 8802(Rev. October 2009 )Certain telephone numbers, fax numbers, and addresses in the Instructions for Form8802 (Rev. October 2009 ) have changed. The correct information is provided Number for Residency Certification UnitYou can contact the Residency Certification Unit by calling (267) 941-1000 (not atoll-free call). Call this number if you have questions about your application for certification ( form 8802) or you need more information about a foreign claimform.

Form 8802 (Rev. October 2009) Department of the Treasury Internal Revenue Service Application for United States Residency Certification OMB No. 1545-1817 2 3a Applicant’s name

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Transcription of Form 8802 (Rev. October 2009) - yoshimura-sr.com

1 Userid:NEDICK00 DTD noticeLeadpct: 0%Pt. size: to PrintPAGER/XMLF ileid:..qbb\documents\2011 Corporate Products\ form 8802\ (Init. & date)Page 1 of 1 Changes to Telephone Numbers, Fax Numbers, and Addresses in the Instructions for form 8802(Rev. October 2009 )9:46 - 24-FEB-2011 The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before of the TreasuryInternal Revenue ServiceNotice1417(February 2011)Changes to Telephone Numbers, Fax Numbers, andAddresses in the Instructions for form 8802(Rev. October 2009 )Certain telephone numbers, fax numbers, and addresses in the Instructions for Form8802 (Rev. October 2009 ) have changed. The correct information is provided Number for Residency Certification UnitYou can contact the Residency Certification Unit by calling (267) 941-1000 (not atoll-free call). Call this number if you have questions about your application for certification ( form 8802) or you need more information about a foreign claimform.

2 See Foreign Claim form on page 4 of the Instructions for form 8802 for of form 8802 after Electronic PaymentThe address and fax numbers for submitting form 8802 after electronic payment of theuser fee have changed. After electronic payment of the user fee, you must either mailForm(s) 8802 to the address below, or fax form (s) 8802 to one of the numbers or Private Delivery ServiceIf you paid the user fee by electronic payment, you can mail form (s) 8802 to thefollowing of the TreasuryInternal Revenue ServicePhiladelphia, PA 19255-0625 FaxIf you paid the user fee by electronic payment, you can fax form (s) 8802 to one of thefax numbers below. These are not toll-free numbers.(267) 941-1035(267) 941-1366 Payment of User Fee by Check or Money OrderIf you paid the form 8802 user fee by check or money order, the addresses to whichyou must send form (s) 8802 have not changed. See Payment by Check or MoneyOrder on page 2 of the Instructions for form No. 57364 VForm8802(Rev. October 2009 )Department of the TreasuryInternal Revenue ServiceApplication for United StatesResidency CertificationOMB No.

3 1545-181723aApplicant s nameIf a joint return was filed, spouse s name (see instructions)Applicant s taxpayer identification numberApplicant s address during the calendar year for which certification is requested, including country and ZIP or postal code. If box, see Information (see instructions) lawful permanent resident (green card holder)Mail form 6166 to the following address:Applicant is (check appropriate box(es)):Individual. Check all applicable Check all applicable If incorporated in the United States only, go to line 5. Otherwise, Privacy Act and Paperwork Reduction Act Notice, see separate No. 10003 DForm8802(Rev. 10- 2009 )abcdeDual-status resident (see instructions). From to 4If a joint return was filed, spouse s taxpayeridentification numberSection 269 BSection 943(e)(1)Section 953(d)Section 1504(d)Trust. Check if:Grantor ( )SimpleGrantor (foreign)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 corporationfgEmployee benefit plan/trust.

4 Plan number, if applicable Section 401(a)Section 403(b)Exempt organization. If organized in the United States, check all applicable 501(c)Other (specify) Section 457(b)Other resident alien. Type of entry visa 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 abovebCheck if:Check if:CAF No. Phone No. Fax No. ()()LLCRev. Rul. 81-100 TrustSection 584 IRA (for Individual) citizenSole proprietorPartial-year form 2555 filer (see instructions). resident from to 501(c)(3)Additional request (see instructions)IRA (for Financial Institution)Disregarded entity. Check if:iIndian tribeGovernmental entityNominee applicant (must specify the type of entity/individual for whom the nominee is acting) jForeign claim form attachedLLCLPLLPO ther (specify) Appointee Name Electronic payment confirmation no. Current nonimmigrant status and date of change (see instructions) See separate year(s) for which certification is period(s) on which certification will be based (see instructions).

5 Purpose of certification. Must check applicable box (see instructions).Form8802(Rev. 10- 2009 ) form 8802 (Rev. 10- 2009 )Income taxVAT (specify NAICS codes) Other (must specify) Under penalties of perjury, I declare that I have examined this application and accompanying attachments, and to the best of my knowledge andbelief, 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 s signature (or individual authorized to sign for the applicant)Keep acopy Applicant s daytime phone no.:Was the applicant s parent, parent organization or owner required to file a tax form ? (Complete this line only if you checked No on line 5.)10409901065990-T104155001120and taxpayer identification number Check the appropriate box for the form filed by the explanation (see instructions).

6 (specify) Parent s/owner s name and address Name and title (print or type)Spouse s signature. If a joint application, both must (print or type)Was the applicant required to file a tax form for the tax period(s) on which certification will be based?10409901065990-T104152271120 Check the appropriate box for the form filed and go to line (specify) Attach explanation (see instructions). Check applicable box and go to line childOther DRE5500 Section 761(a) electionForeign partnershipFASITF oreign DRE3520-A10 Enter penalties of perjury statements and any additional required information here (see instructions).DateApplicant name:Page2 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 penaltiesof perjury statement from Table 2 of the instructions must be entered on line 10 or attached to form 8802 (see instructions).11 Enter the number of certifications needed in the column to the right of each country for which certification is (Rev.)

7 10- 2009 ) form 8802 (Rev. 10- 2009 )Page3 CountryCountry#ArmeniaAustraliaAustriaAz erbaijanApplicant NameAppointee Name (If Applicable)User Fee Voucher for Residency Certification ApplicationApplicant TINFor IRS use only:Pmt Amt $Date Pmt Verified:Column ACCC olumn B#CCCountryColumn C#CCCountryColumn D#CCAMASAUAJB arbadosBelarusBelgiumBBBOBEC anadaCAChinaCyprusCzech RepublicDenmarkDAEZCYCHC olumn A - TotalColumn B - TotalColumn C - TotalColumn D - TotalEgyptEstoniaFinlandFranceEGENFIFRG eorgiaGermanyGGGMG reeceGRHungaryHUIcelandICIndiaINIndonesi aIDIrelandIsraelItalyJamaicaJapanKazakhs tanKorea, SouthKyrgyzstanLatviaLGKGKSKZJAJMITISEIL ithuaniaLuxembourgLHLUM exicoMXMoldovaMDMoroccoMONew ZealandNZNetherlandsNLNorwayPakistanPhil ippinesRPPKNOP olandPortugalRomaniaRussiaRSROPOPLS lovak RepublicLOSloveniaSouth AfricaSISFS painSPSri LankaCESwitzerlandSZTajikistanTIThailand THTrinidad and TobagoTDTunisiaTurkeyTurkmenistanUkraine United KingdomUKUPTXTUTSV enezuelaVE12aEnter the total number of certifications requested (addcolumns A, B, C, and D of line 11)

8 If the total number of certifications is 20 or less, go to line 13If the total on line a is greater than 20, enter $5 for eachadditional 20 certifications 13 Amount owed. Add lines 12b and 12c $35//bc12a1312b12cCalendar year(s) for which certification is requested (must be the same year(s) indicated on line 7)SwedenSWUzbekistanUZBangladeshBGBermud aBDNumber ofForms 6166 User Fee1 - 20 $ - 40 $ - 60 $ - 80 $ - 100$ ofForms 6166 User Fee101 - 120$ - 140$ - 160$ - 180$ - 200$ If you are requesting certifications for more than one calendar year per country, enter the total number of certifications for allyears for each country (see instructions).BulgariaBUDeposit Date://


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