Form 13614NR Nonresident Alien Intake and Interview Sheet

Form 13614-NR
(October 2016)

Nonresident Alien Intake and Interview Sheet

Last or Family Name:

First:

ITIN or Social Security #:
Date of Birth:

Middle Initial:

Visa #:

/

(mm/dd/yyyy)

Passport #:

Telephone #:

/

OMB Number
1545-2075

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

Resident of
India
Yes

No

U.S. Local Street Address:
City:

State:

Zip Code:

Foreign Residence Address:
Address Line 2:
Foreign Country:

Province/County:

Country of Citizenship:
Are you married?

Postal Code:

Country that issued Passport:
Yes

No

If “YES”, is your spouse in the U.S.?

If "YES", is it recognized by the State where you will be filing?
Are you a:

U.S. National
Yes

No

Resident of
Canada
Yes
No

Resident of
Mexico
Yes
No

Yes

No

Yes

No

Resident of
South Korea
Yes
No

Dependent Information

First Name

Last or
Family Name

Date of Birth
(mm/dd/yyyy)

ITIN or SSN

Relationship
to you (son,
daughter,
none, etc.)

/

What is the date you FIRST entered the United States?

U.S. citizen,
U.S. resident
Number of
alien,
months
U.S. national,
Did
lived with or a resident of person file
you in the Canada, Mexico,
joint
U.S.
or South Korea
return?

Did the
Did person Did you
person
provide
provide
have
more than more than
Gross
50% of
50% of Income of
their own
their
$4,050 or
support? support?
more?

/

Entry Immigration Status - Check one:
U.S. Immigrant/Permanent Resident

F-1 Student

F-2 Spouse or child of Student

H-1 Temporary Employee

*J-1 Exchange Visitor

J-2 Spouse or child of Exchange Visitor

U.S. Immigrant/Permanent Resident

F-1 Student

F-2 Spouse or child of Student

H-1 Temporary Employee

*J-1 Exchange Visitor

J-2 Spouse or child of Exchange Visitor

Other: (List)
Current Immigration Status - Check one:

Other: (List)
Have you ever changed your visa type or U.S. immigration status?
If “Yes”, indicate the date and nature of the change.

/

Yes

No

/

Enter the type of U.S. visa you held during these years:
2010

2011

2012

2013

2014

2015

* If Immigration status is J-1, what is the subtype? Check one:
01 Student

05 Professor

02 Short Term Scholar

Other: (List)

12 Research Scholar

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

04 Lecturing

07 Conducting Research

10 Clinical Activities

02 Studying in a Non-Degree Program

05 Observing

08 Training

11 Temporary Employment

03 Teaching

06 Consulting

09 Demonstrating Special Skills

12 Here with Spouse

Form 13614-NR (Rev. 10-2016)

Catalog Number 39748B

www.irs.gov

Department of the Treasury — Internal Revenue Service

Check the years you were present in the United States as a teacher, trainee, or student for any part of the year.
2010

2011

2012

2013

2014

2015

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

Yes

No

How many days (including vacations, nonworkdays and partial days) were you present in the U.S. during:
2014

2015

2016

List the dates you entered and left the United States during 2016:
Date entered United States
mm/dd/yyyy

Date departed United States
mm/dd/yyyy

Date entered United States
mm/dd/yyyy

Did you file a U.S. income tax return for any year before 2016?
/

If “Yes”, give latest year

/

Yes

Date departed United States
mm/dd/yyyy

No

Form number filed

During 2016, 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?
1. Are you claiming the benefits of a U.S. income tax treaty with a foreign country?

Yes
Yes

Yes

No

No
No

If “Yes”, enter the appropriate information in the columns below:
(a) Country

(b) Tax Treaty Article

(c) Number of months
(d) Amount of exempt
claimed in prior tax years income in current tax year

2. Were you subject to tax in a foreign country on any of the income shown in 1(d) above?

Yes

No

Information about academic institution you attended in 2016
Name:

Telephone Number:

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

During 2016 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 Paid

Yes

No

Interest or Dividend Income

Yes

No

State or Local Income Taxes

Yes

No

Distributions from IRA, Pension or Annuity

Yes

No

U.S. 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

Yes

No

IRA Contributions

Yes

No

Yes

No

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

Did you or any dependent have health insurance coverage through HealthCare.gov (The Marketplace)?

Privacy Act and Paperwork Reduction Act Notice
The Privacy Act of 1974 requires that when we ask for information we tell you our legal right to ask for the information, why we are asking for it, and how it will be used. We
must also tell you what could happen if we do not receive it, and whether your response is voluntary, required to obtain a benefit, or mandatory.
Our legal right to ask for information is 5 U.S.C. 301. We are asking for this information to assist us in contacting you relative to your interest and/or participation in the IRS
volunteer income tax preparation and outreach programs. The information you provide may be furnished to others who coordinate activities and staffing at volunteer return
preparation sites or outreach activities. The information may also be used to establish effective controls, send correspondence and recognize volunteers. Your response is
voluntary. However, if you do not provide the requested information, the IRS may not be able to use your assistance in these programs.
The Paperwork Reduction Act requires that the IRS display an OMB control number on all public information requests. The OMB Control Number for this study is 1545-2075.
Also, if you have any comments regarding the time estimates associated with this study or suggestion on making this process simpler, please write to the Internal Revenue
Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, Washington, DC 20224.

Form 13614-NR (Rev. 10-2016)

Catalog Number 39748B

www.irs.gov

Department of the Treasury — Internal Revenue Service