Form 13614-NR Nonresident Alien Intake and Interview Sheet

Form 13614NR
(Rev. 8-2009)

Nonresident Alien Intake and Interview Sheet

Last or Family Name:

First:

(mm/dd/yyyy)

/

Middle Initial:

Visa #:

ITIN or Social Security #:
Date of Birth:

OMB# 1545-2075

/

Telephone #:

(

Passport #:

)

e-mail Address:

Were you a U.S. citizen or resident alien the entire year?

Yes

No

Were you ever a U.S. citizen?

Yes

No

U.S. Local Street Address:
City:

State:

Zip Code:

Foreign Residence Address:
Address Line 2:
Postal Code:

Province/Region:

Foreign Country:

Country of Citizenship:
Are you married?
Are you a:
U.S.National

Country that issued Passport:
Yes

Yes

No

Resident
of Canada

No

Do you have dependents?

If “YES”, is your spouse in the U.S.?

Yes

Yes

No

Resident
of Mexico

No

Yes
Yes

If “YES”, how many?

No
No

Resident of
Republic of Korea

Are they in the United States?

Yes

No

Yes

No

Dependent Information

First Name

Last Name

Date of Birth
(mm/dd/yyyy)

ITIN or SSN

Relationship
to you
(son, daughter, Months
in U.S.
etc.)

/

What is the date you FIRST entered the United States?

U.S. citizen, U.S.
resident alien,
U.S. national, or
a resident of
Canada, Mexico,
or Republic of
Korea

Did
person
file joint
return?

Did the
Did you
Did child
person
provide
provide
have
more than more than
Gross
50% of
50% of
Income
their
their own
of $3,650
support? support? or more?

/

Entry Immigration Status - Check one:
U.S. Immigrant/Permanent Resident
H-1 Temporary Employee
Other: (List)

F-1 Student
J-1 Exchange Visitor

F-2 Spouse or child of Student
J-2 Spouse or child of Exchange Visitor

F-1 Student
J-1 Exchange Visitor

F-2 Spouse or child of Student
J-2 Spouse or child of Exchange Visitor

Current Immigration Status - Check one:
U.S. Immigrant/Permanent Resident
H-1 Temporary Employee
Other: (List)

/

On what date did your visa type change?

/

Enter the type of U.S. visa you held during these years:
2003

2004

2005

2006

2007

2008

If Immigration status is J-1, what is the subtype? Check one:
01 Student
02 Short Term Scholar

05 Professor
Other: (List)

12 Research Scholar

What is the actual primary activity of the visit? Check one:
01 Studying in a Degree Program
02 Studying in a Non-Degree Program

04 Lecturing
05 Observing

07 Conducting Research
08 Training

10 Clinical Activities
11 Temporary Employment

03 Teaching

06 Consulting

09 Demonstrating Special Skills

12 Here with Spouse

Form 13614NR (Rev. 8-2009)

Catalog Number 39748B

Department of the Treasury — Internal Revenue Service

Were you present in the United States as a teacher, trainee or student for any part of 2 of the 6 prior calendar years?
2003

2004

2005

2006

2007

2008

Were you present in the U.S. as a teacher, trainee or student for any part of more than 5 calendar years?

Yes

No

How many days (including vacations, nonworkdays and partial days) were you present in the U.S. during:
2007

2008

2009

List the dates you entered and left the United States during 2009:
Date entered United States
mm/dd/yyyy

Date entered United States
mm/dd/yyyy

Date departed United States
mm/dd/yyyy

Did you file a U.S. income tax return for any year before 2009?
If “Yes”, when
/
/
What form?

Yes

Date departed United States
mm/dd/yyyy

No
Yes

During 2009, did you apply to be a green card holder (lawful permanent resident) of the United States?
Do you have an application pending to change your status to lawful permanent resident?
Are you claiming the benefits of a U.S. income tax treaty with a foreign country?
If “Yes”, enter the appropriate information in the columns below:
(a) Country

(b) Tax Treaty Article

Yes

Yes

No

No

No

(c) Number of months
claimed in prior tax years

(d) Amount of exempt
income in current tax year

Information about academic institution you attended in 2009
Name:

Telephone Number:

Address:
Name of the director of your specialized program:
Address:
Telephone Number:

During 2009 did you receive:

Did you have:

Scholarships or Fellowship Grants

Yes

No

Casualty or Theft Losses

Yes

No

Wages, Salaries or Tips

Yes

No

Student Loan Interest

Yes

No

Interest or Dividend Income

Yes

No

State or Local Income Taxes

Yes

No

Distributions from IRA, Pension or
Annuity

Yes

No

Charitable Contributions

Yes

No

Business Income

Yes

No

Moving Expenses

Yes

No

Unemployment Compensation

Yes

No

Business Expenses

Yes

No

Capital gains or losses

Yes

No

Child/Dependent Care Expenses

Yes

No

Any Other Income
(gambling, lottery, rents, royalties, etc.)

Yes

No

IRA Contributions

Yes

No

Form 13614NR (Rev. 8-2009)

Catalog Number 39748B

Department of the Treasury — Internal Revenue Service