Provisional Tax Statement Worksheet Instructions

The IRS requires that all aliens before departing the United States obtain a Certificate of Compliance (also referred to as a Sailing Permit or Departure Permit). Please see link under Related Information for IRS details. The Provisional Tax Statement Worksheet is completed to obtain a sailing permit.

When to Complete a Provisional Tax Statement Worksheet 

The individuals required to obtain a sailing permit are the H-1, O and P visa holders and the Permanent Resident status. The department of the departing alien should complete a Provisional Tax Statement Worksheet and submit it to Payroll Services a least 1 month prior to departure and no earlier than 60 days.

How to Complete a Provisional Tax Statement Worksheet

  1. Prepared by: Enter name of the person preparing the document
  2. Department: Enter the name of the department
  3. Ext.: Enter telephone number of person preparing worksheet
  4. Employee’s name: Name of the foreign individual
  5. Date leaving U.S.: Enter the date of departure from the U.S.
  6. Date leaving UCLA: Enter the date of departure from UCLA
  7. Date returning: Enter the return date if the trip abroad is temporary
  8. Reason for leaving: Enter the reason for departing the U.S.
  9. Alien status: Choose the appropriate statement and fill in the missing information
  10. Final month’s earning calculation:
    • From/to: List the dates that the employee will be paid for during the final month.
    • Time: Indicate number of hours or % of the month to be to be paid, the final pay rate, and calculate the gross wages.
  11. Terminal vacation pay calculation: Indicate the hours accrued for vacation, the final pay rate, and calculate the gross vacation payment.
  12. Signature: The department chair or designee should sign the worksheet. Note: A second signature is needed when the employee is paid by two different departments.

Completion of Provisional Tax Statement Worksheet

Upon receipt of a completed worksheet, Payroll Services will prepare the Provisional Tax Statement. Payroll Services will notify the Department when the statement has been completed and is ready for pickup.

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