Form 1040NR Information

U.S. Nonresident Alien Income Tax Return

about Form 1040NR and its separate instructions is at www.irs.gov/form1040nr.
OMB No. 1545-0074

Department of the Treasury

Internal Revenue Service beginning
For the year January 1December 31, 2015, or other tax year
, 2015, and ending , 20 2015
Your first name and initial Last name Identifying number (see instructions)

Present home address (number, street, and apt. no., or rural route). If you have a P.O. box, see instructions. Check if: Individual
Please print Estate or Trust
or type City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions).

Foreign country name Foreign province/state/county Foreign postal code

Filing 1 Single resident of Canada or Mexico or single U.S. national 4 Married resident of South Korea
Status 2 Other single nonresident alien 5 Other married nonresident alien
3 Married resident of Canada or Mexico or married U.S. national 6 Qualifying widow(er) with dependent child (see instructions)
Check only If you checked box 3 or 4 above, enter the information below.
one box. (i) Spouses first name and initial (ii) Spouses last name (iii) Spouses identifying number

Exemptions 7a
b
Yourself. If someone can claim you as a dependent, do not check box 7a . . . .
Spouse. Check box 7b only if you checked box 3 or 4 above and your spouse did not
have any U.S. gross income . . . . . . . . . . . . . . . . . . .
c Dependents: (see instructions) (2) Dependents (3) Dependents (4) if qualifying
} Boxes checked
on 7a and 7b
No. of children
on 7c who:
lived with you
identifying number relationship to you child for child tax
If more (1) First name Last name credit (see instr.) did not live with
than four you due to divorce
dependents, or separation (see
instructions)
see instructions.
Dependents on 7c
not entered above

Add numbers on
d Total number of exemptions claimed . . . . . . . . . . . . . . . . . lines above

8 Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . . . . . . . 8

Income
9a Taxable interest . . . . . . . . . . . . . . . . . . . . . . . . 9a
Effectively
b Tax-exempt interest. Do not include on line 9a . . . . . 9b
Connected
With U.S. 10a Ordinary dividends . . . . . . . . . . . . . . . . . . . . . . . 10a
Trade/ b Qualified dividends (see instructions) . . . . . . . . 10b
Business 11 Taxable refunds, credits, or offsets of state and local income taxes (see instructions) . . 11
12 Scholarship and fellowship grants. Attach Form(s) 1042-S or required statement (see instructions) 12
13 Business income or (loss). Attach Schedule C or C-EZ (Form 1040) . . . . . . . . 13
14 Capital gain or (loss). Attach Schedule D (Form 1040) if required. If not required, check here 14
15 Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . . . . . 15
Attach Form(s)
W-2, 1042-S, 16a IRA distributions . . 16a 16b Taxable amount (see instructions) 16b
SSA-1042S, 17a Pensions and annuities 17a 17b Taxable amount (see instructions) 17b
RRB-1042S,
and 8288-A 18 Rental real estate, royalties, partnerships, trusts, etc. Attach Schedule E (Form 1040) . . 18
here. Also 19 Farm income or (loss). Attach Schedule F (Form 1040) . . . . . . . . . . . . 19
attach Form(s)
1099-R if tax
20 Unemployment compensation . . . . . . . . . . . . . . . . . . . 20
was withheld. 21 Other income. List type and amount (see instructions) 21
22 Total income exempt by a treaty from page 5, Schedule OI, Item L (1)(e) 22
23 Combine the amounts in the far right column for lines 8 through 21. This is your total
effectively connected income . . . . . . . . . . . . . . . . . . 23
24 Educator expenses (see instructions) . . . . . . . . 24
Adjusted 25 Health savings account deduction. Attach Form 8889 . . . 25
Gross 26 Moving expenses. Attach Form 3903 . . . . . . . . 26
Income 27 Deductible part of self-employment tax. Attach Schedule SE (Form 1040) 27
28 Self-employed SEP, SIMPLE, and qualified plans . . . . 28
29 Self-employed health insurance deduction (see instructions) 29
30 Penalty on early withdrawal of savings . . . . . . . . 30
31 Scholarship and fellowship grants excluded . . . . . . 31
32 IRA deduction (see instructions) . . . . . . . . . . 32
33 Student loan interest deduction (see instructions) . . . . 33
34 Domestic production activities deduction. Attach Form 8903 . 34
35 Add lines 24 through 34 . . . . . . . . . . . . . . . . . . . . . 35
36 Subtract line 35 from line 23. This is your adjusted gross income . . . . . . . 36
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see instructions. Cat. No. 11364D Form 1040NR (2015)
Form 1040NR (2015) Page 2
37 Amount from line 36 (adjusted gross income) . . . . . . . . . . . . . . . 37
Tax and 38 Itemized deductions from page 3, Schedule A, line 15 . . . . . . . . . . . 38
Credits 39 Subtract line 38 from line 37 . . . . . . . . . . . . . . . . . . . . 39
40 Exemptions (see instructions) . . . . . . . . . . . . . . . . . . . 40
41 Taxable income. Subtract line 40 from line 39. If line 40 is more than line 39, enter -0- . 41
42 Tax (see instructions). Check if any tax is from: a Form(s) 8814 b Form 4972 42
43 Alternative minimum tax (see instructions). Attach Form 6251 . . . . . . . . . 43
44 Excess advance premium tax credit repayment. Attach Form 8962 . . . . . . . . 44
45 Add lines 42, 43, and 44 . . . . . . . . . . . . . . . . . . . . 45
46 Foreign tax credit. Attach Form 1116 if required . . . . . 46
47 Credit for child and dependent care expenses. Attach Form 2441 47
48 Retirement savings contributions credit. Attach Form 8880 . 48
49 Child tax credit. Attach Schedule 8812, if required . . . . 49
50 Residential energy credits. Attach Form 5695 . . . . . 50
51 Other credits from Form: a 3800 b 8801 c 51
52 Add lines 46 through 51. These are your total credits . . . . . . . . . . . . 52
53 Subtract line 52 from line 45. If line 52 is more than line 45, enter -0- . . . . . . 53
54 Tax on income not effectively connected with a U.S. trade or business from page 4, Schedule NEC, line 15 54
Other 55 Self-employment tax. Attach Schedule SE (Form 1040) . . . . . . . . . . . 55
Taxes 56 Unreported social security and Medicare tax from Form: a 4137 b 8919 56
57 Additional tax on IRAs, other qualified retirement plans, etc. Attach Form 5329 if required 57
58 Transportation tax (see instructions) . . . . . . . . . . . . . . . . . 58
59a Household employment taxes from Schedule H (Form 1040) . . . . . . . . . . 59a
b First-time homebuyer credit repayment. Attach Form 5405 if required . . . . . . . 59b
60 Taxes from: a Form 8959 b Instructions; enter code(s) 60
61 Add lines 53 through 60. This is your total tax . . . . . . . . . . . . . 61
62 Federal income tax withheld from:
Payments a Form(s) W-2 and 1099 . . . . . . . . . . . . . 62a
b Form(s) 8805 . . . . . . . . . . . . . . . . 62b
c Form(s) 8288-A . . . . . . . . . . . . . . . 62c
d Form(s) 1042-S . . . . . . . . . . . . . . . 62d
63 2015 estimated tax payments and amount applied from 2014 return 63
64 Additional child tax credit. Attach Schedule 8812 . . . . 64
65 Net premium tax credit. Attach Form 8962 . . . . . . 65
66 Amount paid with request for extension to file (see instructions) 66
67 Excess social security and tier 1 RRTA tax withheld (see instructions) 67
68 Credit for federal tax paid on fuels. Attach Form 4136 . . . 68
69 Credits from Form: a 2439 b Reserved c 8885 d 69
70 Credit for amount paid with Form 1040-C . . . . . . . 70
71 Add lines 62a through 70. These are your total payments . . . . . . . . . 71
72 If line 71 is more than line 61, subtract line 61 from line 71. This is the amount you overpaid 72
Refund 73a Amount of line 72 you want refunded to you. If Form 8888 is attached, check here . 73a
Direct deposit? b Routing number c Type: Checking Savings
See
instructions. d Account number
e If you want your refund check mailed to an address outside the United States not shown on page 1, enter it here.

74 Amount of line 72 you want applied to your 2016 estimated tax 74

Amount 75 Amount you owe. Subtract line 71 from line 61. For details on how to pay, see instructions 75
You Owe 76 Estimated tax penalty (see instructions) . . . . . . . 76
Third Party Do you want to allow another person to discuss this return with the IRS (see instructions)? Yes. Complete below. No
Designee Phone Personal identification
Designees 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
Sign Here belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Your signature Date Your occupation in the United States If the IRS sent you an Identity
Keep a copy of
Protection PIN, enter it here
this return for

(see inst.)
your records.

Print/Type preparer's name Preparer's signature Date PTIN

Paid Check if
self-employed
Preparer
Firm's name Firm's EIN
Use Only
Firm's address Phone no.
Form 1040NR (2015)
Form 1040NR (2015) Page 3

Schedule AItemized Deductions (see instructions) 07

Taxes You
Paid 1 State and local income taxes . . . . . . . . . . . . . . . . . . . 1
Caution: If you made a gift and received a benefit in
Gifts return, see instructions.
to U.S. 2 Gifts by cash or check. If you made any gift of $250 or more,
Charities see instructions . . . . . . . . . . . . . . 2
3 Other than by cash or check. If you made any gift of $250 or
more, see instructions. You must attach Form 8283 if the
amount of your deduction is over $500 . . . . . . . 3

4 Carryover from prior year . . . . . . . . . . . 4

5 Add lines 2 through 4 . . . . . . . . . . . . . . . . . . . . . 5

Casualty and
Theft Losses 6 Casualty or theft loss(es). Attach Form 4684. See instructions . . . . . . . . . 6
Job 7 Unreimbursed employee expensesjob travel, union dues,
Expenses job education, etc. You must attach Form 2106 or Form
and Certain 2106-EZ if required. See instructions
Miscellaneous 7
Deductions

8 Tax preparation fees . . . . . . . . . . . . . 8

9 Other expenses. See instructions for expenses to deduct

here. List type and amount

10 Add lines 7 through 9 . . . . . . . . . . . . 10

11 Enter the amount from Form

1040NR, line 37 . . . . . 11

12 Multiply line 11 by 2% (0.02) . . . . . . . . . . 12

13 Subtract line 12 from line 10. If line 12 is more than line 10, enter -0- . . . . . . . 13
14 Othersee instructions for expenses to deduct here. List type and amount
Other
Miscellaneous
Deductions

14
15 Is Form 1040NR, line 37, over the amount shown below for the filing status box you
Total
checked on page 1 of Form 1040NR:
Itemized
Deductions $309,900 if you checked box 6,
$258,250 if you checked box 1 or 2, or
$154,950 if you checked box 3, 4, or 5?
No. Your deduction is not limited. Add the amounts in the far right column for lines 1
through 14. Also enter this amount on Form 1040NR, line 38.
Yes. Your deduction may be limited. See the Itemized Deductions Worksheet in the
instructions to figure the amount to enter here and on Form 1040NR, line 38. 15
Form 1040NR (2015)
Form 1040NR (2015) Page 4
Schedule NECTax on Income Not Effectively Connected With a U.S. Trade or Business (see instructions)
Enter amount of income under the appropriate rate of tax (see instructions)
Nature of income (d) Other (specify)
(a) 10% (b) 15% (c) 30%
% %
1 Dividends paid by:
a U.S. corporations . . . . . . . . . . . . . . . . . . 1a
b Foreign corporations . . . . . . . . . . . . . . . . . 1b
2 Interest:
a Mortgage . . . . . . . . . . . . . . . . . . . . . 2a
b Paid by foreign corporations . . . . . . . . . . . . . . . 2b
c Other . . . . . . . . . . . . . . . . . . . . . . 2c
3 Industrial royalties (patents, trademarks, etc.) . . . . . . . . . . 3
4 Motion picture or T.V. copyright royalties . . . . . . . . . . . 4
5 Other royalties (copyrights, recording, publishing, etc.) . . . . . . . 5
6 Real property income and natural resources royalties . . . . . . . 6
7 Pensions and annuities . . . . . . . . . . . . . . . . . 7
8 Social security benefits . . . . . . . . . . . . . . . . . 8
9 Capital gain from line 18 below . . . . . . . . . . . . . . 9
10 GamblingResidents of Canada only. Enter net income in column (c).
If zero or less, enter -0-.
a Winnings
b Losses . . . . . . . . . . . . . 10c
11 Gambling winningsResidents of countries other than Canada.
Note: Losses not allowed . . . . . . . . . . . . . . . . 11
12 Other (specify)
12
13 Add lines 1a through 12 in columns (a) through (d) . . . . . . . . 13
14 Multiply line 13 by rate of tax at top of each column . . . . . . . 14
15 Tax on income not effectively connected with a U.S. trade or business. Add columns (a) through (d) of line 14. Enter the total here and on
Form 1040NR, line 54 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Capital Gains and Losses From Sales or Exchanges of Property
Enter only the capital gains and (f) LOSS (g) GAIN
losses from property sales or 16 (a) Kind of property and description (b) Date (c) Date
(e) Cost or other If (e) is more If (d) is more
exchanges that are from (if necessary, attach statement of acquired sold (d) Sales price basis than (d), subtract (d) than (e), subtract (e)
sources within the United descriptive details not shown below) (mo., day, yr.) (mo., day, yr.)
from (e) from (d)
States and not effectively
connected with a U.S. business.
Do not include a gain or loss on
disposing of a U.S. real
property interest; report these
gains and losses on Schedule D
(Form 1040).
Report property sales or
exchanges that are effectively
connected with a U.S. business
on Schedule D (Form 1040), 17 Add columns (f) and (g) of line 16 . . . . . . . . . . . . . . . . . . . . . . 17 ( )
Form 4797, or both. 18 Capital gain. Combine columns (f) and (g) of line 17. Enter the net gain here and on line 9 above (if a loss, enter -0-) 18
Form 1040NR (2015)
Form 1040NR (2015) Page 5

Schedule OIOther Information (see instructions)

Answer all questions
A Of what country or countries were you a citizen or national during the tax year?

B In what country did you claim residence for tax purposes during the tax year?

C Have you ever applied to be a green card holder (lawful permanent resident) of the United States? . . . . . . Yes No

D Were you ever:

1. A U.S. citizen? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
2. A green card holder (lawful permanent resident) of the United States? . . . . . . . . . . . . . . Yes No
If you answer Yes to (1) or (2), see Pub. 519, chapter 4, for expatriation rules that apply to you.

E If you had a visa on the last day of the tax year, enter your visa type. If you did not have a visa, enter your U.S.
immigration status on the last day of the tax year.

F Have you ever changed your visa type (nonimmigrant status) or U.S. immigration status? . . . . . . . . . Yes No
If you answered Yes, indicate the date and nature of the change.

G List all dates you entered and left the United States during 2015 (see instructions).
Note: If you are a resident of Canada or Mexico AND commute to work in the United States at frequent intervals,
check the box for Canada or Mexico and skip to item H . . . . . . . . . Canada Mexico

Date entered United States Date departed United States Date entered United States Date departed United States
mm/dd/yy mm/dd/yy mm/dd/yy mm/dd/yy

H Give number of days (including vacation, nonworkdays, and partial days) you were present in the United States during:
2013 , 2014 , and 2015 .

I Did you file a U.S. income tax return for any prior year? . . . . . . . . . . . . . . . . . . . Yes No
If Yes, give the latest year and form number you filed . . .

J Are you filing a return for a trust? . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

If Yes, did the trust have a U.S. or foreign owner under the grantor trust rules, make a distribution or loan to a
U.S. person, or receive a contribution from a U.S. person? . . . . . . . . . . . . . . . . . . Yes No

K Did you receive total compensation of $250,000 or more during the tax year? . . . . . . . . . . . . Yes No
If Yes, did you use an alternative method to determine the source of this compensation? . . . . . . . . Yes No

L Income Exempt from TaxIf you are claiming exemption from income tax under a U.S. income tax treaty with a
foreign country, complete (1) through (3) below. See Pub. 901 for more information on tax treaties.
1. Enter the name of the country, the applicable tax treaty article, the number of months in prior years you claimed the treaty
benefit, and the amount of exempt income in the columns below. Attach Form 8833 if required (see instructions).

(a) Country (b) Tax treaty (c) Number of months (d) Amount of exempt
article claimed in prior tax years income in current tax year

(e) Total. Enter this amount on Form 1040NR, line 22. Do not enter it on line 8 or line 12 . . . . . .
2. Were you subject to tax in a foreign country on any of the income shown in 1(d) above? . . . . . . . . Yes No
3. Are you claiming treaty benefits pursuant to a Competent Authority determination? . . . . . . . . . Yes No
If "Yes," attach a copy of the Competent Authority determination letter to your return.
Form 1040NR (2015)