University of California, Berkeley
Supplemental Foreign Income Information
2009-2010
Student Name:_______________________________ Social Security Number:_______________________
S.I.D. #:____________________________________
Please answer all the following questions pertaining to your foreign sources of income for the year 2008. DO NOT
INCLUDE ANY AMOUNT THAT IS INCLUDED ON A U.S. INCOME TAX RETURN.
Attach copies of all foreign tax documents and translations to verify amounts reported.
In what currency is the foreign income?_________________ From what country?______________
1a. What is the total number of people in your family? (1a)______
1b. Marital status: o Married o Single
1c. Name of Family Member Relationship Support Provided
to Student Age Number of Months
___________________________ ___________________ ______ ________
___________________________ ___________________ ______ ________
___________________________ ___________________ ______ ________
___________________________ ___________________ ______ ________
___________________________ ___________________ ______ ________
___________________________ ___________________ ______ ________
Foreign Exchange In US
Currency Rate Dollars
2. Enter the amount you or your spouse earned from employment by others. (2)_______ ______ ______
3. Enter the amount of interest you received from banks or other sources. (3)_______ ______ ______
4. Enter the amount you received in dividends from ownership of stock. (4)_______ ______ ______
5. Enter the amount of income or loss you had as a result of owning or (5)_______ ______ ______
operating a business or professional entity.
6. Enter the amount of gain or loss you had from the sale of assets, investments, (6)_______ ______ ______
or capital property. (Please describe on the back of this sheet, and include
the original cost, and the selling price.)
7. Enter the amount you received from personal retirement funds or annuities. (7)_______ ______ ______
8. Enter the amount of retirement pension income from employers. (8)_______ ______ ______
9. Enter the amount of income you received from the operation of rental (9)_______ ______ ______
operations or from royalties or copyright payments.
10. Enter the amount of income you received from farming. (10)_______ ______ ______
11. Enter the amount of unemployment income subsidies you received from (11)_______ ______ ______
insurance or the government.
12. Enter the amount of government disability, survivor, or retirement pensions (12)_______ ______ ______
received.
13. Enter the amount of any other income you had that is not listed above or on (13)_______ ______ ______
a US tax return.
14. Enter the amount of income tax paid to governments other than the US. (14)_______ ______ ______
15. Enter the total amount of all cash savings, and attach copies of year-end (15)_______ ______ ______
statements.
16. Enter the value of all corporate stock and partnership values. (16)_______ ______ ______
17. Enter the value of all properties other than the family residence. (17)_______ ______ ______
18. Enter the amount of mortgages, if any, on the properties above; do not (18)_______ ______ ______
include any amount for the family residence.
_________________________________ ___________________ _________________________________
Tax Payer Signature Date Tax Payer SSN (if available)
Forms; SupplementalforeignIncome; ldp 3/2/09
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