University Of Massachusetts Tax Information Sheet Form
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2UNIVERSITY OF MASSACHUSETTS TAX INFORMATION SHEET
All non-U.S. citizens who receive compensation/scholarships/fellowships from the University must complete this
form. The information provided is used to determine status for participation in tax treaties and/or for purposes of
withholding of U.S. income taxes from paychecks. It is NOT used for immigration purposes.
DATE OF BIRTH ________/__________/_________
FIRST DATE OF ENTRY INTO THE US ________/_________/________
Family name
First name
Middle name (If Any)
U.S. Social Security Number
Street Address in U.S.
Home (Cell) phone number
City
State
Zip Code
Work phone number :
E-mail Address:
Student ID #- (if applicable)
VISA INFORMATION
(RED) VISA NUMBER _______________________________ ISSUE DATE _____/______/______
(Bottom right corner)
CURRENT VISA TYPE: (please circle type below)
Permanent Resident Card (green card) **Card Expires**________________
U.S. Permanent Resident with green card or with an I-551 stamp in passport or with approval letter, you are a
Resident Alien for tax purposes. (If you are a Permanent Resident, you do not need to complete the remainder
or the reverse side of this form).** PLEASE SIGN REVERSE SIDE**
F-1 student
J-2 spouse/dependent
*Required DS2019-Box 4 ______________________
F1student on Practical Training
F-2 spouse/dependent of F-1
*
J-1
H-1 B visa holder
__________________________
EAD card #
____________________________
*Required DS2019-Box 4 _______________________
Other: please specify _______________________
PASSPORT INFORMATION
PASSPORT NUMBER________________________
EXPIRATION DATE _____/_______/________
What is your country of citizenship? ________________________________
______
What country were you in and paying taxes prior to coming to US?
What is the end date on your I-20 form?
mm/_______ dd/_______yyyy ________
What is the end date on your DS2019 form
? mm/_____ dd/ _____ yyyy _______
PLEASE COMPLETE OTHER SIDE OF FORM
The following forms are used by Human Resources to verify your status for tax purposes
*Permament Resident – Either Green Card or Valid EAD with approval letter for residency or a
passport showing a stamp stating “Processed for I-551”
*F-1 Student: I-20 and I-94; if on practical training, either an EAD or authorization on reverse of I-20
*J-1 Student: DS2019 and I-94; if on academic training, letter of authorization
*J-1 Non Student: form DS2019 and I-94
*J-2 with employment permission: EAD and I-94
*H-1B: I-94 and I-797
*TN: I-94 and photo identification
11.24.2014
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