Form 13614nr - Nonresident Alien Intake And Interview Sheet
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1
2OMB Number
13614NR
Form
Nonresident Alien Intake and Interview Sheet
1545-2075
(Rev. October 2015)
Last or Family Name:
First:
Middle Initial:
ITIN or Social Security #:
Visa #:
Passport #:
Date of Birth:
Telephone #:
e-mail Address:
/
/
(mm/dd/yyyy)
Were you a U.S. citizen or resident alien the entire year?
Yes
No
Were you ever a U.S. citizen?
Yes
No
U.S. Local Street Address:
City:
State:
Zip Code:
Foreign Residence Address:
Address Line 2:
Foreign Country:
Province/County:
Postal Code:
Country of Citizenship:
Country that issued Passport:
Are you married?
Yes
No
If “YES”, is your spouse in the U.S.?
Yes
No
If "YES", is it recognized by the State where you will be filing?
Yes
No
Are you a:
U.S. National
Resident of
Resident of
Resident of
Resident of
Canada
Mexico
South Korea
India
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Dependent Information
U.S. citizen,
Did the
U.S. resident
Did child
Did you
person
Number of
alien,
provide
provide
have
Relationship
months
U.S. national,
Did
more than
more than
Gross
to you (son,
lived with
or a resident of
person file
50% of
50% of
Income of
Last or
Date of Birth
daughter,
you in the
Canada, Mexico,
joint
their own
their
$4,000 or
First Name
Family Name
(mm/dd/yyyy)
ITIN or SSN
none, etc.)
U.S.
or South Korea
return?
support?
support?
more?
What is the date you FIRST entered the United States?
/
/
Entry Immigration Status - Check one:
U.S. Immigrant/Permanent Resident
F-1 Student
F-2 Spouse or child of Student
H-1 Temporary Employee
*J-1 Exchange Visitor
J-2 Spouse or child of Exchange Visitor
Other:
(List)
Current Immigration Status - Check one:
U.S. Immigrant/Permanent Resident
F-1 Student
F-2 Spouse or child of Student
H-1 Temporary Employee
*J-1 Exchange Visitor
J-2 Spouse or child of Exchange Visitor
Other:
(List)
Have you ever changed your visa type or U.S. immigration status?
Yes
No
If “Yes”, indicate the date and nature of the change.
/
/
Enter the type of U.S. visa you held during these years:
2009
2010
2011
2012
2013
2014
* If Immigration status is J-1, what is the subtype? Check one:
01 Student
05 Professor
12 Research Scholar
02 Short Term Scholar
Other:
(List)
What is the actual primary activity of the visit? Check one:
01 Studying in a Degree Program
04 Lecturing
07 Conducting Research
10 Clinical Activities
02 Studying in a Non-Degree Program
05 Observing
08 Training
11 Temporary Employment
03 Teaching
06 Consulting
09 Demonstrating Special Skills
12 Here with Spouse
13614-NR
Form
(Rev. 10-2015)
Catalog Number 39748B
Department of the Treasury — Internal Revenue Service
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