U.S. Nonresident Alien Income Tax Return: Filing Status
U.S. Nonresident Alien Income Tax Return: Filing Status
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Digital Assets At any time during 2022, did you: (a) receive (as a reward, award, or payment for property or services); or (b) sell, exchange, gift, or
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otherwise dispose of a digital asset (or a financial interest in a digital asset)? (See instructions.) . . . . . .
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Yes ✔ No
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Credit for other
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(1) First name Last name identifying number (3) Relationship to you dependents
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instructions and
check here
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Income 1a Total amount from Form(s) W-2, box 1 (see instructions) . . . . . . . . . . . . . 1a 9637
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With U.S. d Medicaid waiver payments not reported on Form(s) W-2 (see instructions) . . . . . . . . 1d
Trade or
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10 Adjustments to income:
a From Schedule 1 (Form 1040), line 26 . . . . . . . . . . . 10a
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d Enter the amount from line 10a. These are your total adjustments to income . . . . . . . 10d
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11 Subtract line 10d from line 9. This is your adjusted gross income . . . . . . . . . . 11 9637
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12 Itemized deductions (from Schedule A (Form 1040-NR)) or, for certain residents of India, standard
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13a Qualified business income deduction from Form 8995 or Form 8995-A . 13a
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14 14 12950
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For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 11364D
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Tax and 16 Tax (see instructions). Check if any from Form(s): 1 8814 2 4972 3 16
Credits 17 Amount from Schedule 2 (Form 1040), line 3 . . . . . . . . . . . . . . . . . 17
18 Add lines 16 and 17 . . . . . . . . . . . . . . . . . . . . . . . . 18
19 Child tax credit or credit for other dependents from Schedule 8812 (Form 1040) . . . . . . 19
20 Amount from Schedule 3 (Form 1040), line 8 . . . . . . . . . . . . . . . . . 20
21 Add lines 19 and 20 . . . . . . . . . . . . . . . . . . . . . . . . 21
22 Subtract line 21 from line 18. If zero or less, enter -0- . . . . . . . . . . . . . . 22 0
23a Tax on income not effectively connected with a U.S. trade or business from
Schedule NEC (Form 1040-NR), line 15 . . . . . . . . . . 23a
b Other taxes, including self-employment tax, from Schedule 2 (Form 1040),
line 21 . . . . . . . . . . . . . . . . . . . . 23b
c Transportation tax (see instructions) . . . . . . . . . . . 23c
d Add lines 23a through 23c . . . . . . . . . . . . . . . . . . . . . . 23d
24 Add lines 22 and 23d. This is your total tax . . . . . . . . . . . . . . . . . 24 0
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c 25c
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26 2022 estimated tax payments and amount applied from 2021 return . . . . . . . . . . 26
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32 32 1000
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33 Add lines 25d, 25e, 25f, 25g, 26, and 32. These are your total payments . . . . . . . . 33 1742
Refund 34 If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid . . 34
35a Amount of line 34 you want refunded to you. If Form 8888 is attached, check here . . . . 35a 1742
Direct deposit? b Routing number 1 1 1 9 0 0 6 5 9 c Type: Checking ✔ Savings
See instructions.
d Account number 1 2 0 2 8 0 8 9 5 0
e If you want your refund check mailed to an address outside the United States not shown on page 1,
enter it here.
36 Amount of line 34 you want applied to your 2023 estimated tax . . 36
Amount 37 Subtract line 33 from line 24. This is the amount you owe.
You Owe For details on how to pay, go to [Link]/Payments or see instructions . . . . . . . . 37
38 Estimated tax penalty (see instructions) . . . . . . . . . . 38
Third Do you want to allow another person to discuss this return with the IRS? See instructions. Yes. Complete below. No
Party Designee’s Phone Personal identification
Designee name no. number (PIN)
Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and
belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Sign Your signature Date Your occupation If the IRS sent you an Identity
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(see inst.)
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2015623565
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Preparer
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