Nra 001 Foreign National Information Form Page 2
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2Describe the activity that will result in U.S. income (i.e. employee, professor of physics, consulting, teaching assistant, food service worker, scholarship,
contest prize, etc.) ________________________________________________________ What is the start date of this activity?_____________________
Name of agency/department providing the income: __________________________
Amount: ______________________*
Payment Type:
[ ] Wages
[ ] Scholarship
[ ] Honorarium
[ ] Other_____________________
* For Wages the amount should be the estimated annual income (Calendar Year).
TAX EXEMPTIONS INFORMATION
Is your spouse in the U.S.? [ ] Yes
[ ] No
Is your spouse employed?
[ ] Yes
[ ] No
Do you want to claim an exemption for your spouse if legally allowed to do so?
[ ] Yes
[ ] No
Do you have other dependents in the U.S. you would like to claim exemptions for?
[ ] Yes
[ ] No
If so, how many? _______
RESIDENCY VERIFICATION
What country did you live in before this visit to the U.S.? ____________________________________________
Did you pay taxes as a resident of that country?
[ ] Yes [ ] No
Please list the dates of residency in that country?
_
_/____/_____
_____/____/_____
month/ day/ year
month/ day/ year
U.S. IMMIGRATION HISTORY, Part 1
Have you ever had another immigration status in the United States? [ ] Yes
[ ] No
Have you ever been present in the United States before this visit?
[ ] Yes
[ ] No
U.S. IMMIGRATION HISTORY, Part 2 - REQUIRED
Please complete your immigration history for the past 5 years. If you do not know exact dates, please estimate each arrival and departure date. If you are
in F, J, M, or Q visa status, please include all arrival and departure activities since January 1, 1985. Please note this section is REQUIRED for all visa types.
Date of US Entry Date of US Exit
Have you Taken Any
month/day/year
month/day/year
Visa/Immigration Status
J-1 Subtype
Primary Activity
Treaty Benefits?
___/__/___
___/__/___
_____________
_________
____________
[ ] Yes
[ ] No
___/__/___
___/__/___
_____________
_________
____________
[ ] Yes
[ ] No
___/__/___
___/__/___
_____________
_________
____________
[ ] Yes
[ ] No
___/__/___
___/__/___
_____________
_________
____________
[ ] Yes
[ ] No
___/__/___
___/__/___
_____________
_________
____________
[ ] Yes
[ ] No
___/__/___
___/__/___
_____________
_________
____________
[ ] Yes
[ ] No
Foreign National's Signature: I hereby certify that all of the above information is true and correct. I understand that if ANY of my information
changes, including status, from that which I have indicated on this form I must submit a new Foreign Visitor Information Form.
Signature: _____________________________________________
Date: _______________________________
Consent and Authorization to Release Information
I, __________________________________ (foreign national's name) hereby authorize the North Carolina entity listed to release
information contained on the Foreign Visitor Information Form to Thomson Reuters, Inc. for the following purpose: technical software
support for THE WINDSTAR INTERNATIONAL TAX NAVIGATOR SYSTEM.
Signature: _________________________________________
Date ___________________________
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