Full Name

E-mail

Phone Number

In what country do you currently reside?

In what country or countries have you resided in during the past 5 years?

When was the last time (tax year) you filed a tax return?

What date did you move away from the U.S.?

Do you pay foreign taxes?
YesNo

My work situation can be described as: (check all that apply)
EmployeeSelf-EmployedUS Business OwnerForeign Business OwnerRetired

What is the amount of your annual compensation or business profits?
$0 - $50,000$50,000 - $100,000$100,000 - $200,000$200,000 - $500,000$500,000+

Do you have a non-U.S. retirement account?
YesNo

Do you own or sign on any non-US bank or financial accounts?
YesNo

If yes, approximately how many?

Do you own any of the following foreign investments outside of an employer retirement plan: mutual funds, ETFs, unit trusts, life insurance, annuities?
YesNo

If yes, please provide more information on the the accounts.

Are you currently under audit or have you received any IRS correspondence?
YesNo

Do you own any U.S. based property or U.S. brokerage accounts?
YesNo

Do you own any foreign corporations or partnerships?
YesNo

Other (please add any other relevant information)