Form 9212 — Income Questionnaire

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f9212.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

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(April 2015)

Department of the Treasury - Internal Revenue Service

Taxpayer's name and address In reply refer to:

Tax year

Last four digits of Social Security Number

To assist us in the examination of your tax return, complete all parts of this questionnaire and provide the requested information.

Part I - Form 2555

Submit the following for each Form 2555 filed with your return.

1. A complete copy of your employment contract or a letter of agreement signed by you and your employer outlining the terms and conditions of your employment.

2. An employer prepared statement from your U.S. based company itemizing the actual compensation amounts received and/or the value of non-cash compensation paid to you or provided by your U.S. employer on your behalf.

3. If a Form W-2 was issued, provide a reconciliation of the compensation reported on the W-2 and the compensation statement provided by your U.S. employer.

4. An employee prepared statement from the foreign affiliate of your U.S. employer, or the foreign company for which you worked, itemizing the actual compensation received and/or the value of non-cash compensation paid to you or provided by your foreign employer.

5. The enclosed Compensation Questionnaire, and Form 8768 - Questionnaire-Dividends, Interest, Rents, Royalties, and Other Income.

Part II - Partnership Income

Complete the following questions and submit the requested information on the partnership who employs you.

1. Are you a partner or a general partner in the entity you reported to be your employer Yes No

If yes, submit the following:

a. A complete copy of the partnership agreement;

b. The partnership annual income summary statement; and,

c. A copy of the foreign tax return filed by the partnership.

2. If you were a partner, did you receive any of the following:

a. A guaranteed salary Yes No

If yes, show amount $

b. Did you receive any additional allowances Yes No

If Yes, show amount(s) on enclosed Compensation Questionnaire.

c. Did you receive a percentage of the profit or loss of the partnership Yes No

If yes, what percentage %

d. Did the partnership conduct business in the U.S., or receive income from U.S. sources for

this tax year

Yes No

If yes, what was the percentage of the partnership's U.S. income in relation to its % worldwide business activity

Catalog Number 11844Q www.irs.gov Form 9212 (Rev. 4-2015)

Part III - Income from A Closely Held Business

Complete the following questions and submit the requested information on the entity that employs you.

1. Do you, a member of your family, or any other related party, own any stock or have a controlling interest, either directly, indirectly (through a partnership, corporation, trust, etc.), or constructively, in the entity which employs you?

If yes, provide the following information:

a. Name(s)

b. Relationship (include self)

c. Social security number

d. Number of shares owned

e. Percentage of shares owned

f. Type of shares owned Common Preferred Voting Non-voting

Remarks

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Yes No

Certification: Under penalty of perjury, I declare that I have examined this statement and, to the best of my knowledge and belief, it is true, correct, and complete.