Fillable International Tax Questionnaire Form printable pdf download

Page 1

IU INTERNATIONAL TAX QUESTIONNAIRE

To be completed by all international visitors

Instructions for International Tax Questionnaire (ITQ)

Step 1: Complete appropriate pages of questionnaire

Page 1: To be completed by all international visitors

Page 2: To be completed by international visitors receiving wages or salary as an employee of Indiana

University

Page 3: To be completed by international students at Indiana University

Page 4: To be completed by independent contractors, short-term visitors, research participants, and all o

ther non-U.S.

persons receiving payments from Indiana University

Step 2: Send completed ITQ, copy of I-94, and sponsoring document (e.g. I-20, DS-2019) to:

Financial Management Services, Poplars Bldg Room 527, Bloomington, IN 47405

** IUPUI Employees ONLY: IUPUI Payroll, UN442, Indianapolis, IN 46202

Individual Information – Basic Info

. Last Name (Family Name) or Legal Name of Business Entity: ________________________________________________

. First Name (Given Name): _________________________

. Middle Name: ____________________________________

. Date of Birth (Month/Day/Year): ____/____/______

. Tax ID Number - Social Security (SSN) OR Individual Taxpayer Identification (ITIN) OR Employer Identification (EIN)

Applied for: ________ SSN: __________________ TIN: ___________________ EIN: ___________________

Individual Information – USA Address and Foreign Address

. United States Address Line 1: _______________________________________________________________

Address Line 2: _____________________________________________________________________

City: ________________________________________ State: _____________ Zip: _______________

. Foreign Address Line 1: ____________________________________________________________________

Line 2: _____________________________________________________________________________

City: ___________________________________________City Postal Code: _____________________

Province/Region: ____________________________________________________________________

Province/Region Postal Code: _____________________ Country: _____________________________

Individual Information – Personal Info

. Telephone Number: (______) ______-________

. Email Address: _________________________________

. Date that you first entered the United States (U.S.) in your lifetime (Month/Day/Year): ____/____/_______

Individual Information – Country Info

. Country that issued passport: _____________________________ Passport number: ____________________

. Country of tax residence (where you pay taxes outside of the United States): ________________________

Individual Information - Def Income 2

. Have you applied for Lawful Permanent Residence in the United States: __________ Yes _________ No

. Have you received Lawful Permanent Resident Status (green card): __________ Yes _________ No

Please enter the number here and attach a copy of the card _____________________________________

. Do you wish to claim exemption from tax withholding if tax treaty benefits are available: __________ Yes _________ No

Visa Detail

. Have you claimed a tax treaty exemption in prior calendar years? If yes, please provide the following information:

Calendar Year

Treaty Country of Benefits

Benefits Claimed under Article

(Study, Teaching, Research, Other)

__________

_______________________________

__________

_______________________________

I declare that my responses to this questionnaire are true and complete.

Signature: _______________________________________________ Date: _______________________

Last Updated: October 10, 2007

Clear Fields

Email questions about completing this form to

taxpayer@indiana.edu

or call 812.855.0375

International Tax Questionnaire Form

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