Form Upp-192 - Alien Determination Of Residency
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1
2FOR PAYROLL USE ONLY
THE UNIVERSITY OF CHICAGO
Visa:__________
FICA: Y N
UPP-192 – ALIEN DETERMINATION OF RESIDENCY
Entr: __________ Start: __________
Exp: __________
Resident
Ctry: __________ Non-Resident
All applicable questions must be answered. Attach copies of documents listed on the back of this form. This form
Entered by: ______________________
and documents must be returned to Payroll Services (6054 S. Drexel, Suite 300) before any payment will be issued.
SECTION I. PAYEE INFORMATION
Name (Last, First)
Email
SSN or ITIN
Country of Citizenship
Country of Residence (Do not indicate US)
Department (of employment)
Passport Issued by (Country) and Passport Number
Visa Number (not control number)
UC Student ID (If Applicable)
SECTION II. CURRENT ALIEN STATUS
Change of Status to Permanent Resident
F1 Student on ”Practical Training” (OPT or CPT)
H-1B Employee
Permanent Resident Applicant
J1 Student
J2 Spouse/Dependent of a J1
Non-Student
B1, WB, WT (Business)
J1 Student on “Academic Training”
J2 Spouse/Dependent of a J1 Student
F1 Student
J1 Non-Student (Research Scholar,
Other USCIS Classification: __________
Professor, Short-Term Scholar)
SECTION III. IMMIGRATION INFORMATION
(Permanent Residents skip to Section IV)
Furnish the information to detail the number of days of physical presence in the US for each calendar year.
List Calendar
Number of days of
Periods (dates of
Visa/USCIS
Were tax treaty
Year
physical presence
physical presence
classification
benefits taken?
EXAMPLE
2015
350
01/15/15 – 12/31/15
J1 Student
NO
Current Year
Last Calendar Year
2 Years Ago
3 Years Ago
4 Years Ago
5 Years Ago
6 Years Ago
Date of first entry into the US (not as a tourist)
USCIS visa classification held during first
Expiration date of current USCIS
Anticipated date of departure from the US
entry
classification
SECTION IV. CERTIFICATION AND SIGNATURE
I certify that to the best of my knowledge all of the information provided above is true, correct and complete.
_______________________________________________
_____________________________
Signature
Date (MM/DD/YY)
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