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OMB No. 1545-0074U.S. Income Tax Return for CertainNonresident
Aliens With No Dependents
Form
Department of the TreasuryInternal Revenue Service
Identifying number (see page 4)Last nameYour first name and
initial
Present home address (number, street, and apt. no., or rural
route). If you have a P.O. box, see page 4.
City, town or post office, state, and ZIP code. If you have a
foreign address, see page 4.
Country
Single nonresident alien1 Married nonresident alien2
3Wages, salaries, tips, etc. Attach Form(s) W-2 (see pages 4 and
5)3
Taxable refunds, credits, or offsets of state and local income
taxes (see page 5)
12
Scholarship and fellowship grants. Attach Form(s) 1042-S or
required statement (see page 5)
13
Add lines 3, 4, and 5
1040NR-EZ
Cat. No. 21534N Form 1040NR-EZ (2009
Total income exempt by a treaty from page 2, Item J(1)(e) 6
4
5
6
7
4
5
98
9
Scholarship and fellowship grants excluded (see page 6)
Subtract the sum of line 8 and line 9 from line 7. This is your
adjusted gross income
Itemized deductions (see page 7)11
14
15
18
2021
Subtract line 11 from line 10
Exemption (see page 7)
Taxable income. Subtract line 13 from line 12. If line 13 is
more than line 12, enter -0-
Tax. Find your tax in the Tax Table on pages 17 through 25
Federal income tax withheld (from Forms W-2, 1042-S, and
1099-R)
2009 estimated tax payments and amount applied from 2008
return
Credit for amount paid with Form 1040-C
11
12
13
14
15
18
SignHereKeep a copy ofthis return foryour records.
PaidPreparersUse Only
Under penalties of perjury, I declare that I have examined this
return and accompanying schedules and statements, and to the best
of my knowledgeand belief, they are true, correct, and accurately
list all amounts and sources of U.S. source income I received
during the tax year. Declaration ofpreparer (other than taxpayer)
is based on all information of which preparer has any
knowledge.
Your signature Your occupation in the United States
Preparerssignature
Check ifself-employed
Preparers SSN or PTIN
Firms name (oryours if self-employed),address, and ZIP code
EIN
Date
10 10
Unreported social security and Medicare tax from Form:
Add lines 15 and 16. This is your total tax
19 19
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice,
see page 15.
Add lines 18 through 20. These are your total payments 21
22
23a
25
16 16
Student loan interest deduction (see page 6)
17
20
8
7
17
Date
Phone no. ( )
23a
24 24
If line 21 is more than line 17, subtract line 17 from line 21.
This is the amount you overpaid
25
Amount of line 22 you want refunded to you.
If Form 8888 is attached, check here
Refund
26
Amount of line 22 you want applied to your 2010 estimated
tax
Estimated tax penalty (see page 9). Also include on line
2526
AmountYou Owe
Amount you owe. Subtract line 21 from line 17. For details on
how to pay, see page 9
Directdeposit? Seepage 8 andfill in 23b,23c, and23d, orForm
8888.
Routing number
Account number
c Checking SavingsType:b
d
22
Designees
name
Do you want to allow another person to discuss this return with
the IRS (see page 10)?ThirdPartyDesignee Phone
no. ( )
Yes. Complete the following. No
Personal identification
number (PIN)
a 4137 8919b
2009
e If you want your refund check mailed to an address outside the
United States notshown above, enter that address here:
Pleaseprint ortype.
AttachFormsW-2 or1042-Shere.
Alsoattach
Form(s)1099-R iftax waswithheld.
Enclose,but do notattach, anypayment.
Filing Status
Check only one box.
8/14/2019 2009 Form1040NR-EZ
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Page 2Form 1040NR-EZ (2009)
Other Information (see page 10)
Of what country or countries were you a citizen or national
during the tax year?A
In what country did you claim residence for tax purposes during
the tax year?B
NoYesHave you ever applied to be a green card holder (lawful
permanent resident) of the United States?C
D
E What was your visa type on the last day of the tax year?
List all dates you entered and left the United States during
2009 (see page 10).
Note. If you are a resident of Canada or Mexico AND enter and
leave the United States at frequent
intervals,check the box for Canada or Mexico
and skip to question H
F
1.
Give number of days (including vacation, nonworkdays, and
partial days) you were present in the United States during
2007 , 2008 , and 2009 .
G
Enter the name of the country, the applicable tax treaty
article, the number of months in prior years you claimed the
treaty benefit, and the amount of exempt income in the columns
below. Attach Form 8833 if required (see page 10).
Did you file a U.S. income tax return for any prior year?
J
If Yes, give the latest year and form number you filed NoYes
NoYes
Income Exempt from TaxIf you are claiming the benefits of a U.S.
income tax treaty with a foreign country, complete 1
and 2 below. See Pub. 901 for more information on tax
treaties.
I
Form 1040NR-EZ (2009)
Were you ever:
NoYes
2. A green card holder (lawful permanent resident) of the United
States? NoYes
Have you ever changed your visa type (nonimmigrant status)?
NoYes
H
2. Were you subject to tax in a foreign country on any of the
income shown in 1(d) above?
(e) Total. Enter this amount on Form 1040NR-EZ, line 6. Do not
enter it on line 3 or line 5
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1. A U.S. citizen?
If you answer Yes to 1 or 2, see Pub. 519, chapter 4, to see
expatriation rules that apply to you.
Date entered United States
mm/dd/yy
Date departed United States
mm/dd/yy
MexicoCanada
Date entered United States
mm/dd/yy
Date departed United States
mm/dd/yy
(a) Country (b) Tax treatyarticle
(c) Number of monthsclaimed in prior tax years
(d)Amount of exemptincome in current tax year
