1040NR

U.S. Nonresident Alien Income Tax Return

OMB No. 1545-0074

Form

For the year January 1–December 31, 2005, or other tax year

beginning

005

Department of the Treasury Internal Revenue Service

, 2005, and ending

, 20

Your first name and initial

Last name

Identifying number (see page 8 of inst.)

Country

Of what country were you a citizen or national during the tax year?

Give address outside the United States to which you want any refund check mailed. If same as above, write “Same.”

Give address in the country where you are a permanent resident. If same as above, write “Same.”

234561

Single resident of Canada or Mexico, or a single U.S. national

	

Other single nonresident alien

	

Married resident of Canada or Mexico, or a married U.S. national If you check box 7b, enter your spouse’s

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Married resident of Japan (see page 9) or the Republic of Korea fidentifying number

Other married nonresident alien

	

Qualifying widow(er) with dependent child (see page 9)

Caution: Do not check box 7a if your parent (or someone else) can claim you as a dependent. Do not check box 7b if your spouse had any U.S. gross income.

on 7a and 7b

No. of boxes checked

No. of children on

7c who:

● lived with you

● did not live with

you due to divorce

or separation

Dependents on 7c

not entered above

d

Total number of exemptions claimed

	

Add numbers entered on lines above

8 Wages, salaries, tips, etc. Attach Form(s) W-2 9a Taxable interest

	

	

b Tax-exempt interest. Do not include on line 9a 10a Ordinary dividends

	

9b

	

b Qualified dividends (see page 11)

	

10b

11 Taxable refunds, credits, or offsets of state and local income taxes (see page 11)
12 Scholarship and fellowship grants. Attach Form(s) 1042-S or required statement (see page 11) 13 Business income or (loss). Attach Schedule C or C-EZ (Form 1040)

	

14 Capital gain or (loss). Attach Schedule D (Form 1040) if required. If not required, check here
15 Other gains or (losses). Attach Form 4797

	

16aIRA distributions

	

16b Taxable amount (see page 12) 17b Taxable amount (see page 13)

17aPensions and annuities

18Rental real estate, royalties, partnerships, trusts, etc. Attach Schedule E (Form 1040)
19 Farm income or (loss). Attach Schedule F (Form 1040)
20 Unemployment compensation

	

	

21 Other income. List type and amount (see page 14)

22 Total income exempt by a treaty from page 5, Item M

22

23 Add lines 8, 9a, 10a, 11–15, 16b, and 17b–21. This is your total effectively connected income

24 Educator expenses (see page 14)

	

25 Health savings account deduction. Attach Form 8889 26Moving expenses. Attach Form 3903

	

27 Self-employed SEP, SIMPLE, and qualified plans

	

28 Self-employed health insurance deduction (see page 15) 29Penalty on early withdrawal of savings

	

30 Scholarship and fellowship grants excluded

	

31IRA deduction (see page 15)
32 Student loan interest deduction (see page 16)

	

	

33Domestic production activities deduction. Attach Form 8903 34 Add lines 24 through 33

	

34

35 Subtract line 34 from line 23. Enter here and on line 36. This is your adjusted gross income

35

Cat. No. 11364D

Form 1040NR (2005)

Present home address (number, street, and apt. no., or rural route). If you have a P.O. box, see page 8.

City, town or post office, state, and ZIP code. If you have a foreign address, see page 8.

	Check if:	□	Individual	
		□	Estate or Trust	
	For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see page 30.	

Filing Status and Exemptions for Individuals (see page 8)		7a	7b	
Filing status. Check only one box (1–6 below).		Yourself	Spouse	

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7c Dependents: (see page 9)
(1) First name
Last name	(2) Dependent’s identifying number	(3) Dependent’s
relationship
to you	(4)	if qualifying
child for child tax
credit (see page 9)	
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Form 1040NR (2005)

Page 2

36 Amount from line 35 (adjusted gross income)

	

37 Itemized deductions from page 3, Schedule A, line 17
38 Subtract line 37 from line 36
39 Exemptions (see page 17)

	

	

	

40Taxable income. Subtract line 39 from line 38. If line 39 is more than line 38, enter -0-

41Tax (see page 17). Check if any tax is from: a

Form(s) 8814 b

Form 4972

42 Alternative minimum tax (see page 18). Attach Form 6251 43Add lines 41 and 42

	

	

44 Foreign tax credit. Attach Form 1116, if required

	

45 Credit for child and dependent care expenses. Attach Form 2441
46 Retirement savings contributions credit. Attach Form 8880
47 Child tax credit (see page 19). Attach Form 8901 if required
48 Adoption credit. Attach Form 8839

	

49 Credits from: a

Form 8396

b

Form 8859

	

50 Other credits. Check applicable box(es): a

Form 3800

b

 Form 8801 c

Form

	

51 Add lines 44 through 50. These are your total credits

	

51

52 Subtract line 51 from line 43. If line 51 is more than line 43, enter -0-

	

52

53 Tax on income not effectively connected with a U.S. trade or business from page 4, line 88
54 Social security and Medicare tax on tip income not reported to employer. Attach Form 4137
55 Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 5329 if required
56 Transportation tax (see page 21)

	

	

57 Household employment taxes. Attach Schedule H (Form 1040)
58 Add lines 52 through 57. This is your total tax

	

59 Federal income tax withheld from Forms W-2, 1099, 1042-S, etc.
60 2005 estimated tax payments and amount applied from 2004 return 61Excess social security and tier 1 RRTA tax withheld (see page 22) 62 Additional child tax credit. Attach Form 8812

	

63Amount paid with Form 4868 (request for extension)

	

64 Other payments from: a

Form 2439 b

Form 4136 c

Form 8885

65Credit for amount paid with Form 1040-C

	

66U.S. tax withheld at source from page 4, line 85

	

67 U.S. tax withheld at source by partnerships under section 1446:

a From Form(s) 8805
b From Form(s) 1042-S

	

	

68 U.S. tax withheld on dispositions of U.S. real property interests: a From Form(s) 8288-A

	

b From Form(s) 1042-S

	

69Add lines 59 through 68b. These are your total payments

	

69

Refund

70 If line 69 is more than line 58, subtract line 58 from line 69. This is the amount you overpaid 71aAmount of line 70 you want refunded to you.

bRouting number

c Type:

Checking

Savings

d Account number

Direct

deposit? See

page 22.

72 Amount of line 70 you want applied to your 2006 estimated tax

72

Amount

73 Amount you owe. Subtract line 69 from line 58. For details on how to pay, see page 23

You Owe

74 Estimated tax penalty. Also include on line 73

74

Third Party

Do you want to allow another person to discuss this return with the IRS (see page 24)?

Yes. Complete the following.

Designee’s

Phone

Personal identification

name

no.

number (PIN)

No

Designee

Sign

Under penalties of perjury, I declare that I have examined this return and belief, they are true, correct, and complete. Declaration of preparer (other tha

schedules and statements, and to the best of my knowledge and n taxpayer) is based on all information of which preparer has any knowledge.

Here

Your signature

Date

Your occupation in the United States

Keep a copy

of this

return for

your records.

Paid

Preparer’s

signature

Date

Check if

self-employed

Preparer’s SSN or PTIN

Pre‑

parer’s

Firm’s name (or

Use Only

yours if self-employed),

address, and ZIP code

Form 1 040NR (2005)

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Form 1040NR (2005)

Page 3

Schedule A—Itemized Deductions (See pages 24, 25, 26, and 27.)

07

State and

1 State income taxes

	

Local

Income

2 Local income taxes
3 Add lines 1 and 2

	

Taxes

	

3

Total Gifts

Caution: If you made a gift and received a benefit in

to U.S.

return, see page 24.

Charities

4a Total gifts by cash or check. If you made any gift of $250 or more, see page 24

	

4a

4b Gifts by cash or check after

August 27, 2005, that you elect to treat as qualified contributions (see page 25)

4b

5 Other than by cash or check. If you made any gift of $250 or

more, see page 24. You must attach Form 8283 if “the amount of your deduction” (see definition on page 25) is more than $500

5

6 Carryover from prior year

	

6

7 Add lines 4a, 5, and 6

	

7

Casualty and

Theft Losses

8 Casualty or theft loss(es). Attach Form 4684. See page 25

	

8

Job

9 Unreimbursed employee expenses—job travel, union

Expenses

dues, job education, etc. You must attach Form 2106

and Certain

or Form 2106-EZ if required. See page 26

Miscellaneous

Deductions

10 Tax preparation fees

	

11 Other expenses. See page 26 for expenses to deduct

here. List type and amount

11

12 Add lines 9 through 11

	

13 Enter the amount from Form 1040NR, line 36

	

13

14 Multiply line 13 by 2% (.02)

	

15 Subtract line 14 from line 12. If line 14 is more than line 12, enter -0-

15

Other

16 Other—see page 26 for expenses to deduct here. List type and amount

Miscellaneous

Deductions

16

Total

17 Is Form 1040NR, line 36, over $145,950 (over $72,975 if you checked filing status box 3, 4, or 5 on page 1 of Form 1040NR)?

~
No. Your deduction is not limited. Add the amounts in the far right column

for lines 3 through 16. Also enter this amount on Form 1040NR, line 37.

Yes. Your deduction may be limited. See page 27 for the amount to

enter here and on Form 1040NR, line 37.

Itemized

Deductions

17

Form 1 040NR (2005)

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Form 1040NR (2005)

Page 4

Tax on Income Not Effectively Connected With a U.S. Trade or Business
Attach Forms 1042-S, SSA-1042S, RRB-1042S, or similar form.

Nature of income

(a) U.S. tax

withheld

at source

Enter amount of income under the appropriate rate of tax (see page 27)

(b) 10%

(c) 15%

(d) 30%

(e) Other (specify)

%

%

75 Dividends paid by: a U.S. corporations

	

b Foreign corporations

	

76

Interest:

a Mortgage

	

b Paid by foreign corporations

	

c Other

	

77

Industrial royalties (patents, trademarks, etc.)

78 Motion picture or T.V. copyright royalties

	

79 Other royalties (copyrights, recording, publishing, etc.)
80 Real property income and natural resources royalties
81 Pensions and annuities
82 Social security benefits

	

	

83 Gains (include capital gain from line 91 below)

84 Other (specify)

85 Total U.S. tax withheld at source. Add column (a) of lines 75a through 84. Enter the total here and on Form

1040NR, line 66

	

85

86 Add lines 75a through 84 in columns (b)–(e)

	

86

87 Multiply line 86 by rate of tax at top of each column

	

87

88 Tax on income not effectively connected with a U.S. trade or business. Add columns (b)–(e) of line 87. Enter the total here and on Form

1040NR, line 53

	

88

Capital Gains and Losses From Sales or Exchanges of Property

Enter only the capital gains and losses from property sales or exchanges that are from sources within the United States and not effectively connected with a U.S. business. Do not include a gain or loss on disposing of a U.S. real property interest; report these gains and losses on Schedule D (Form 1040).

89 (a) Kind of property and description

(if necessary, attach statement of descriptive details not shown below)

(b) Date

acquired

(mo., day, yr.)

(c) Date

sold

(mo., day, yr.)

(d) Sales price

(e) Cost or other

basis

(f) LOSS

If (e) is more

than (d), subtract (d)

from (e)

(g) GAIN

If (d) is more

than (e), subtract (e)

from (d)

Report property sales or exchanges that are effectively connected with a U.S. business on Schedule D (Form 1040), Form 4797, or both.

(

)

90 Add columns (f) and (g) of line 89

	

90

91

Capital gain. Combine columns (f) and (g) of line 90. Enter the net gain here and on line 83 above (if a loss, enter -0-)

91

Form 1 040NR (2005)

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Form 1040NR (2005)

Page 5

Other Information (If an item does not apply to you, enter “N/A.”)

A What country issued your passport?

Yes

No

and current nonimmigrant status and date

of change (see page 27)

residence as an immigrant in the United States this year?

	

Yes

No

the United States at frequent intervals, give name of country

only.

nonworkdays) you were present in the United States

during:

2003

, 2004

, and 2005

I If you are a resident of Canada, Mexico, the

Republic of Korea (South Korea), or Japan (and you elect to have the old U.S.-Japan income tax treaty apply in its entirety for 2005) or a U.S. national, did your spouse contribute to the support of any child claimed on Form 1040NR, line 7c?

Yes

No

If “Yes,” enter amount

$

If you were a resident of the Republic of Korea (South Korea) or Japan (and you elect to have the old U.S.-Japan income tax treaty apply in its entirety for 2005) for any part of the tax year, enter in the space below your total foreign source income not effectively connected with a U.S. trade or business. This information is needed so that the exemption for your spouse and dependents residing in the United States (if applicable) may be allowed in accordance with Article 4 of the income tax treaty between the United States and the Republic of Korea (South Korea) or Article 4 of the old income tax treaty between the United States and Japan.

Total foreign source income not effectively connected with

a U.S. trade or business	$

	

Yes

No

If “Yes,” give the latest year and form number

claimed on Form 1040NR, lines 60, 63, and 65?

than foreign source income not effectively connected with a U.S. trade or business?

Yes

No

If “Yes,” show the amount, nature, and source of the

excluded income. Also, give the reason it was excluded.

(Do not include amounts shown in item M.)

M If you are claiming the benefits of a U.S. income tax treaty

with a foreign country, give the following information. See page 28 for additional information.

● Country

● Type and amount of effectively connected income exempt from tax. Also, identify the applicable tax treaty article. Do not enter exempt income on lines 8, 9a, 10a, 11-15, 16b, or 17b–21 of Form 1040NR.

For 2005 (also, include this exempt income on line

22 of Form 1040NR)

For 2004

● Type and amount of income not effectively connected that is exempt from or subject to a reduced rate of tax. Also, identify the applicable tax treaty article.

For 2005

For 2004

● Were you subject to tax in that country on any of the income you claim is entitled to the treaty benefits?

	

Yes

No

● Did you have a permanent establishment or fixed base (as defined by the tax treaty) in the United States at any time during 2005?

Yes

No

N If you file this return to report community income, give your spouse’s name, address, and identifying number.

O If you file this return for a trust, does the trust have a U.S. business?

	

Yes

No

If “Yes,” give name and address

P Is this an “expatriation return” (see page 28)?

	

Yes

No

If “Yes,” you must attach an annual information statement.

Q During 2005, did you apply for, or take

other affirmative steps to apply for, lawful permanent resident status in the United States or have an application pending to adjust your status to that of a lawful permanent resident of the United States?

Yes

No

If “Yes,” explain

B Were you ever a U.S. citizen?

C Give the purpose of your visit to the United States

D	Type of entry visa

E	Date you entered the United States (see page 27)

F Did you give up your permanent

G Dates you entered and left the United States during the year. Residents of Canada or Mexico entering and leaving

H	Give number of days (including vacation and

J Did you file a U.S. income tax return for any year before 2005?

K	To which Internal Revenue office did you pay any amounts

L	Have you excluded any gross income other

Form 1040NR (2005)

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