4361 Application for Exemption From Self-Employment Tax for U

Caution: DRAFT FORM
This is an advance proof copy of an IRS tax form.
It is subject to change and OMB approval before it
is officially released. You can check the scheduled
release date on our web site (www.irs.gov).
If you have any comments on this draft form, you can
submit them to us on our web site. Include the word
DRAFT in your response. You may make comments
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Form

I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 8843, PAGE 1 OF 4
MARGINS; TOP 13mm (1⁄ 2 ”), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 432mm (17”) x 279mm (11”) Fold to 216mm(81⁄ 2 ”) x 279mm(11”)
PERFORATE: ON FOLD
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

8843

Action

Date

O.K. to print
Revised proofs
requested

OMB No. 1545-0074

Statement for Exempt Individuals and Individuals
With a Medical Condition

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2006

For use by alien individuals only.

Department of the Treasury
Internal Revenue Service

beginning

For the year January 1—December 31, 2006, or other tax year
, 2006, and ending
, 20

Your first name and initial

Fill in your
addresses only if
you are filing this
form by itself and
not with your tax
return

Part I

Last name

Address in country of residence

General Information

Attachment
Sequence No.

.

102

Your U.S. taxpayer identification number, if any

Address in the United States

1a Type of U.S. visa (for example, F, J, M, Q, etc.) and date you entered the United States
b Current nonimmigrant status and date of change (see instructions) ©
2
3a
b
4a

Signature

©

Of what country were you a citizen during the tax year?
What country issued you a passport?
Enter your passport number ©
Enter the actual number of days you were present in the United States during:
2006
2005
2004
.
b Enter the number of days in 2006 you claim you can exclude for purposes of the substantial presence test ©

Part II

Teachers and Trainees
©

5

Enter the name, address, and telephone number of the academic institution you attended during 2006

6

Enter the name, address, and telephone number of the director of the academic or other specialized program you participated
in during 2006 ©

7

Enter the type of U.S. visa (J or Q) you held during: ©
2000
2001
2002
2003
2004
2005
. If the type of visa you held during any
of these years changed, attach a statement showing the new visa type and the date it was acquired.
Were you present in the United States as a teacher, trainee, or student for any part of 2 of the 6 prior
calendar years (2000 through 2005)?
Yes
No
If you checked the “Yes” box on line 8, you cannot exclude days of presence as a teacher or trainee
unless you meet the Exception explained on page 3.

8

Part III
9

Students

Enter the name, address, and telephone number of the academic institution you attended during 2006

©

10

Enter the name, address, and telephone number of the director of the academic or other specialized program you participated
in during 2006 ©

11

Enter the type of U.S. visa (F, J, M, or Q) you held during: ©
2000
2001
. If the type of visa you held during any
2002
2003
2004
2005
of these years changed, attach a statement showing the new visa type and the date it was acquired.
Were you present in the United States as a teacher, trainee, or student for any part of more than 5 calendar
Yes
No
years?
If you checked the “Yes” box on line 12, you must provide sufficient facts on an attached statement to
establish that you do not intend to reside permanently in the United States.

12

13

14

During 2006, 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 change your status to that of a lawful
permanent resident of the United States?
If you checked the “Yes” box on line 13, explain ©

For Paperwork Reduction Act Notice, see page 4.

Cat. No. 17227H

Yes

Form

8843

No

(2006)

1
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 8843, PAGE 2 OF 4
MARGINS; TOP 13mm (1⁄ 2 ”), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 432mm (17”) x 279mm (11”) Fold to 216mm(81⁄ 2 ”) x 279mm(11”)
PERFORATE: ON FOLD
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 8843 (2006)

Part IV

Page

Professional Athletes

2

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15

Enter the name of the charitable sports event(s) in the United States in which you competed during 2006 and the dates of
competition ©

16

Enter the name(s) and employer identification number(s) of the charitable organization(s) that benefited from the sports
event(s) ©

Note. You must attach a statement to verify that all of the net proceeds of the sports event(s) were contributed to the charitable
organization(s) listed on line 16.

Part V

Individuals With a Medical Condition or Medical Problem

17a Describe the medical condition or medical problem that prevented you from leaving the United States

©

b Enter the date you intended to leave the United States prior to the onset of the medical condition or medical problem described
on line 17a ©
c Enter the date you actually left the United States
18

©

Physician’s Statement:
I certify that
Name of taxpayer

was unable to leave the United States on the date shown on line 17b because of the medical condition or medical problem
described on line 17a and there was no indication that his or her condition or problem was preexisting.

Name of physician or other medical official

Physician’s or other medical official’s address and telephone number

Physician’s or other medical official’s signature

Sign here
only if you
are filing
this form by
itself and
not with
your tax
return

Date

Under penalties of perjury, I declare that I have examined this form and the accompanying attachments, and to the best of my knowledge and
belief, they are true, correct, and complete.

©

Your signature

©

Date
Form

8843

(2006)