For more information on the meaning of abode see IRS Publication 54. Catalog Number 67042A www.irs.gov Form 14653 Rev. 10-2017 Page of I was physically outside the United States for at least 330 full days answer Yes or No for each year Yes No Both spouses filing a joint certification must meet the non-residency requirement. Form 14653 October 2017 Department of the Treasury - Internal Revenue Service Certification by U.S. Person Residing Outside of the United States for Streamlined Foreign Offshore Procedures Name s of taxpayer s Mailing address TIN s of taxpayer s City OMB Number 1545-2241 Telephone number State ZIP code Note If this certification is a joint certification the statements will be considered made on behalf of both spouses even though the pronoun I is used. If spouses submitting a joint certification have different reasons for their failure to report all income pay all tax and submit all required information returns including FBARs they must state their individual reasons separately in the required statement of facts. I am providing delinquent or amended income tax returns including all required information returns for each of the most recent 3 years for which the U*S* tax return due date or properly applied for extended due date has passed* The tax and interest I owe for each year are as follows Year list years in order Amount of Tax I Owe Shown On Form 1040 or Form 1040X Interest Total Note Your payment should equal the total tax and interest due for all three years. You may receive a balance due notice or a refund if the tax or interest is not calculated correctly. I failed to report income from one or more foreign financial assets during the above period. I meet all the other eligibility requirements for the Streamlined Foreign Offshore procedures. If I failed to timely file correct and complete FBARs for any of the last six years I have now electronically filed those FBARs. I agree to retain all records related to my income and assets during the period covered by my delinquent or amended returns until three years from the date of this certification* If I was required to file delinquent FBARs in accordance with these procedures I also agree to retain all records including but not limited to account statements related to my foreign financial accounts until six years from the date of this certification* Upon request I agree to provide all such records to the Internal Revenue Service. My failure to report all income pay all tax and submit all required information returns including FBARs was due to non-willful conduct. I understand that non-willful conduct is conduct that is due to negligence inadvertence or mistake or conduct that is the result of a good faith misunderstanding of the requirements of the law. I acknowledge the possibility that amended income tax returns I am submitting under the Streamlined Foreign Offshore Procedures may report income for tax years beyond the three-year assessment limitations period under I. R*C. 6501 a. Other assessment limitations periods in I. R*C. 6501 may allow the Internal Revenue Service to assess and collect tax.
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