International Tax Questionnaire Form Page 2
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INTERNATIONAL TAX QUESTIONNAIRE
To be completed by international visitors receiving wages or salary as an employee of Indiana University
Last Name:
First Name:
Employment definition:
You are probably an IU employee if IU makes payments to you on a fixed schedule (biweekly, monthly) based
on hours worked under the direction and control of another university faculty or staff member. You may have a required number of hours to
perform a service, or a set schedule for which you are expected to be working on behalf of IU.
Employee examples:
Associate instructor, graduate assistant, research or teaching assistant, hourly paid work, teacher, researcher,
professor, individual on OPT/CPT.
Individual Information – Basic Info
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. University ID Number (10 digits): ________________________________________
Individual Information – Personal Info
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. Name of Department performing services for: ____________________________________________________
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. Job Title or Occupation: _____________________________
. Estimated annual income: ______________________
Visa Detail
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. Please check your current immigration status and primary purpose:
_______J-1 Student – Select primary purpose
_______Degree seeking
_______Non-degree seeking _______ Full-time Academic Training
_______J-1 Non-student – Select Category and Primary purpose
Category listed on DS-2019:
_______Teacher
_______Professor _______ Research Scholar
_______Alien Physician
_______Camp Counselor
_______Short-term Scholar _______Trainee – Medical
_______ Trainee (non-medical)
_______ Summer Travel/Work
Primary Purpose:
_______Teaching
_______Lecturing
_______Observing
_______Conducting Research
_______Clinical Activities
_______Practical Training
_______Short-term Scholar _______Summer Travel/Work
_______Other_______________________________________
_______J-2 – Here with J-1 Spouse/Parent
_______F-1 student – Select primary purpose
_______Degree seeking
_______Non-degree seeking _______Full-time OPT/CPT
_______H-1B – Select primary purpose
_______Teaching _______Lecturing _______Clinical Activities
_______Research _______Other temp employment
_______Other visa type – list immigration status and specify primary purpose: _________________________
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. Please provide details about your visit history to the U.S. for the last six (6) years as accurately as possible:
Visa Type
Primary Purpose (Study, Research, etc)
Date Arrived (M/D/Y)
Date Departed (M/D/Y)
__________
_______________________________
______________
______________
__________
_______________________________
______________
______________
__________
_______________________________
______________
______________
__________
_______________________________
______________
______________
__________
_______________________________
______________
______________
__________
_______________________________
______________
______________
I declare that my responses to this questionnaire are true and complete.
Signature: _______________________________________________ Date: _______________________
Last Updated: October 10, 2007
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Email questions about completing this form to
taxpayer@indiana.edu
or call 812.855.0375
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