Non-Resident Alien Information Form

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NON-RESIDENT ALIEN INFORMATION FORM
TAX YEAR :
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,) a copy of your U.S. VISA from your passport, and I-20 or IAP66 must be attached to this form. Then bring to Warriner 204 (Payroll/Travel Services
Office)
(1) Last or Family name:
First:
Middle:
(2) Social Security #:
(3) Date of Birth:
(4) U.S. LOCAL ADDRESS:
(5) FOREIGN PERMANENT RESIDENCE ADDRESS:
Line 1:
Line1:
Line 2:
City:
City:
Postal Code:
Province/Region:
State:
Zip:
Foreign Country:
(6) Country of Citizenship:
(7) Country That Issued Passport:
(8) Passport # :
(9) Visa #:
(Not the control number that begins with a year)
(10) Do you have multiple exits and entries to the United States
Yes
No
If yes, list on page 2.
Enter all of your entry and exit dates on the back
(11) IMMIGRATION STATUS:
U.S. Immigrant/Permanent Resident
F-1 Student
J-1 Exchange Visitor
H-1 Temporary Employee
Other: ____________________________
J-2 Spouse or Child of Exchange Visitor
(12) IF IMMIGRATION STATUS IS J-1, WHAT IS THE SUBTYPE? CHECK ONE:
01 Student
05 Professor
12 Research Scholar
02 Short Term Scholar
Other: ______________________________
(13) 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
(14) WHAT IS THE ACTUAL DATE YOU
(15) WHAT IS YOUR HIRE DATE
(16) WHAT IS YOUR PROJECTED
ENTERED THE UNITED STATES?
DEPARTURE DATE
________/________/________
________/________/________
________/________/________
Month
Day
Day
Year
Month
Day
Year
Month
Day
Year
(17) JOB DESCRIPTION
(18) WHAT TYPE STUDENT?
(19) SPOUSE IN USA?
Undergraduate
Masters
Yes
No
( e.g. PROFESSOR OF CHEMISTRY)
Doctoral
Other
Number of Dependents? _____________
(21) COUNTRY OF TAX RESIDENCE IF DIFFERENT FROM FOREIGN
RESIDENCE ADDRESS: (
Did you pay tax in another country other than where you live?
)
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 Non-Resident Alien Information Form to the CMU Payroll Department at Warriner 204.
Signature:
Date:
Local Phone:
E-Mail Address:

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