0515 Form 9250 (PDF)

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f9250.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

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(May 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 - To be completed by all taxpayers

1. I am claiming benefits under Article (Number)

of the tax treaty between the United States and

(Country)

2. I have claimed the benefits shown in Item 1 for the past (Number)

3. I am a citizen of (Country)

4. I am a resident of (Country)

years

5. I entered the United States under a (Letter and Number)

6. My initial date of entry into the United States was (Month, Day, Year)

7. The following are my arrival and departure dates since my initial date of entry:

Arrivals (Month, Day, Year) Departures (Month, Day, Year)

8. Please check one of the following:

a. I am still living in the United States and intend to remain until

b. I am no longer living in the United States

9. The primary purpose of my visit to the United States was to

Page 2

Part III - To be completed by students, apprentices, and trainees only

1. My occupation before coming to the United States was (Kind of Occupation)

2. My occupation when I return to my country will be (Kind of Occupation)

3. I came to the United States at the invitation of:

a. United States Government or Agency

b. Educational Institution

c. Private Organization

d. Other (Explain)

Attach a copy of your invitation from the applicable source.

4. I received my salary from (Name of Payer)

5. I received my grant from (Grantor)

If you received a grant, please enclose a copy

6. I was a full time student at (Educational Institution)

Enclose a statement from the educational institution showing the dates of your attendance

Part IV- Remarks

Remarks

Certification: Under penalties 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.