Form 13614-NR Form 13614-NR Nonresident Alien Intake and Interview Sheet

Department of the Treasury - Internal Revenue Service

Form 13614-NR
(October 2021)

Last or Family Name

First

ITIN or Social Security #
Date of Birth:

Middle Initial

Visa #

/

(mm/dd/yyyy)

OMB Number
1545-2075

Nonresident Alien Intake and Interview Sheet
Passport #

Telephone #

/

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)

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

ITIN or SSN

/

What is the date you FIRST entered the United States?

U.S. citizen,
Number of U.S. resident
months
alien,
lived with
U.S. national,
Did
you in the or a resident of person file
U.S. in Canada, Mexico,
joint
2021
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
$4,300 or
support? support?
more?

/

Were you prevented from exiting the U.S. due to COVID-19, Emergency Travel Disruptions on or after 2-1-2020 and
before 4-2-2020? (This may affect the substantial presence test)

Yes

No

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
2015

2016

2017

2018

2019

2020

* 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

Catalog Number 39748B

www.irs.gov

Form 13614-NR (Rev. 10-2021)

Check the years you were present in the United States as a teacher, trainee, student or as an accompanying spouse or
dependent of a person in such status for any part of the year.
2015
2016
2017
2018
2019
2020
Have you ever been present in the U.S. PRIOR to 2015 on a teacher, trainee, student visa, or as their accompanying spouse or
dependent?
Yes
No If so, what years and visa type
How many days (including vacations, nonworkdays and partial days) were you present in the U.S. during
2019

2020

2021

List the dates you entered and left the United States during 2021
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 2021?
/

If “Yes”, give latest year

/

Yes

Date departed United States
mm/dd/yyyy

No

Form number filed

During 2021, 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 2021
Name

Telephone number

Address
Name of your academic/specialized program director

Telephone number

Address

During 2021 did you receive

Did you have

Scholarships or Fellowship Grants

Yes

No

Wages, Salaries or Tips

Yes

No

Casualty Losses in a Declared Disaster
Area

Yes

No

Interest

Yes

No

Student Loan Interest Paid

Yes

No

Distributions from IRA, Pension or Annuity

Yes

No

State or Local Income Taxes

Yes

No

State or Local Tax Refunds

Yes

No

U.S. Charitable Contributions

Yes

No

Unemployment Compensation

Yes

No

Child/Dependent Care Expenses

Yes

No

Dividend income or capital gains or losses

Yes

No

IRA Contributions

Yes

No

Any Other Income (gambling, lottery, prizes, awards, self-employment, rents, royalties, virtual currency, etc.)

Yes

No

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

Yes

No

If yes, was any Advanced Premium Tax Credit received? (Provide Form 1095-A)

Yes

No

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.

Catalog Number 39748B

www.irs.gov

Form 13614-NR (Rev. 10-2021)