Form 1040NR (2010), Page 5

Summary: This is an example of Form 1040NR (2009), page 5, with items included as described in the text. Additionally, these line items are completed:

A. What country issued your passport? field contains United Kingdom
B. Were you ever a U.S. citizen? No checkbox checked
C. Give the purpose of your visit to the United States field contains Temporary assignment
D. Current nonimmigrant status and date of change (see page 29) field contains Permanent
G. Dates you entered and left the United States during the year. Residents of Canada or Mexico entering and leaving the United States at frequent intervals, give name of country only. field contains
- Entered--March 18, 2009
- Departed--May 25, 2009
- Entered--September 10, 2009
H. Give number of days (including vacation and nonworkdays) you were present in the United States during:
- 2006 field contains 0
- 2009 field contains 0
- and 2009 field contains 182
J. Did you file a U.S. income tax return for any year before 2009? No checkbox checked
M. If you are claiming the benefits of a U.S. income tax treaty with a foreign country, give the following information. See page 30for additional information.
- Country field contains United Kingdom
- Type and amount of income not effectively connected that is exempt from or subject to a reduced rate of tax. Also, identify the applicable tax treaty article: For 2009 field contains Additional income of $240 taxed at 15% under Article 10
- Were you subject to tax in that country on any of the income you claim is entitled to the treaty benefits? Yes checkbox checked
- Did you have a permanent establishment or fixed base (as defined by the tax treaty) in the United States at any time during 2009? No checkbox checked
P. Is this an expatriation return (see page 30)? No checkbox checked
Q. During 2009, did you apply for, or take other affirmative steps to apply for, lawful permanent resident status in the United States or have an application pending to adjust your status to that of a lawful permanent resident of the United States? Yes checkbox checked
Q. During 2009, did you apply for, or take other affirmative steps to apply for, lawful permanent resident status in the United States or have an application pending to adjust your status to that of a lawful permanent resident of the United States? Yes checkbox checked
If Yes, explain field contains Permanent resident status granted
R. Check this box if you have received compensation income of $250,000 or more (see page 30).checkbox blank

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