Musc Purchasing & Ap Tax Information Form For Internationals
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M U S C P U R C H A S I N G & A P T A X I N F O R M A T I O N F O R M F O R I N T E R N A T I O N A L S
( P A G E 1
This form must be completed before you can receive any form of payment from MUSC.
All applicable questions below must be answered. A copy of both sides of your I-94 Form “Arrival and Departure Record”, (a small white card
inside your passport), copy of your U.S. VISA from your passport, and 1-20 or DS2019 or 1797A must be attached to this form. This form must be
returned before any check can be issued by the Accounts Payable Department and must also be completed by anyone receiving tuition
remission/scholarship.
(1)Last or Family Name: _____________________________________First:_____________________________Middle:__________________
(2)Social Security #: _________________________________________ Date of Birth: _____________________________________________
(3) U. S. LOCAL STREET ADDRESS: ______________________
(4) FOREIGN RESIDENCE ADDRESS:_______________________
_______________________________________________________
_________________________________________________________
(3) Address Line 2: ________________________________________
(4) Address Line 2:__________________________________________
(3) Address Line 3: ________________________________________
(4) Address Line 3/City:______________________________________
(3) City:_________________________________________________
(4) Postal Code:____________Province/Region:___________________
(3) State: ____________________________ Zip: _______________
(4) Foreign Country:_________________________________________
(5) Country of Citizenship:____________________________________ (6) Country That Issued Passport: ____________________________
(7) Passport # and Expiration: ________________________________ (8) Visa #:(# in red)_________________________________________
(9) Have you ever had another immigration status or visa waiver in the United States?
Yes.
No If yes, see page 2.
(10) IMMIGRATION STATUS:
J-2 Spouse or Child of Exchange Visitor
U.S. Immigrant/Permanent Resident
F-1 Student
J-1 Exchange Visitor
H-1 Temporary Employee
Other: ___________________________________________________________________________________________________
(11) WHAT IS THE ACTUAL PRIMARY ACTIVITY OF THE VISIT? CHECK ONE:
01 Studying in a Degree Program
05 Observing
09 Demonstrating Special Skills
02 Studying in a Non-Degree Program
06 Consulting
10 Clinical Activities
03 Teaching
07 Conducting Research
11 Temporary Employee
04 Lecturing
08 Training
12 Here with Spouse
(12) WHAT IS THE ACTUAL DATE YOU
(13) WHAT DATE DID YOU EXIT
THE COUNTRY?
FIRST ENTERED THE UNITED STATES
IN YOUR PRESENT STATUS?:
__/__/__
__/__/__
Month/Day/Year
Month/Day/Year
(14)BASE OF OPERATIONS:
Do you/will you have an office (fixed base) in the USA?
es
No If yes, how many days in this tax year did you/will you have office (fixed base)? ___________
(15) COUNTRY OF RESIDENCE IF DIFFERENT FROM FOREIGN RESIDENCE ADDRESS:____________________________
__/__/__
Did tax residency end?
Yes
No
If yes, when?
Month/Day/Year
I hereby certify that all of the above information is true and correct. I understand that if my status changes from that which I have indicated
on this form I must submit a new Tax Information Form to Tax & Cash Management of the Controller's Office
Signature: __________________________________________________ Date: __________ Local Phone Number: _______________________
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