University Of Massachusetts Tax Information Sheet Form Page 2
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2You must list ALL dates you have entered and departed the United States on this page.
UNIVERSITY 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.
US ENTRY DATES
US DEPARTURE DATES
If DS-2019 BOX 4
mm/dd/yyyy
mm/dd/yyyy
Visa Type
J-1 category
List Previous Entries
List Previous Departures
Required
Entry _____/______/_____ ------Departure _____/____/______
_________
______________
Entry _____/______/_____ ------Departure _____/____/______
_________
______________
Entry _____/______/_____ ------Departure _____/____/______
_________
______________
Entry _____/______/_____ ------Departure _____/____/______
_________
______________
Entry _____/______/_____ ------Departure _____/____/______
_________
______________
Entry _____/______/_____ ------Departure _____/____/______
_________
______________
Entry _____/______/_____ ------Departure _____/____/______
_________
______________
Entry _____/______/_____ ------Departure _____/____/______
_________
______________
Entry _____/______/_____ ------Departure _____/____/______
_________
______________
*PRESENT * THIS DATE IS FOR CURRENT VISIT Entry
_________
VISIT
_____/_____/_____
*MUST MATCH THE DATE ON NEWEST I-94
If more space is needed, please use an additional form
PLEASE INDICATE CHANGES IN VISA STATUS
DATE _____/______/______
TYPE CHANGED FROM ________ TYPE CHANGED TO _________
DATE _____/______/______
TYPE CHANGED FROM ________ TYPE CHANGED TO _________
RESIDENCE STATEMENT FOR TAX PURPOSES
I certify that, to the best of my knowledge, all of the information I have provided is true, accurate and complete.
Signature:
Date:
/
/
_____________________________________________________
__________
________
____________
Please sign in English
11.24.2014
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