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8843

Statement for Exempt Individuals and Individuals

OMB No. 1545-0074

2016

Form

With a Medical Condition

For use by alien individuals only.

Information about Form 8843 and its instructions is at

Attachment

102

For the year January 1—December 31, 2016, or other tax year

Sequence No.

Department of the Treasury

beginning

, 2016, and ending

, 20

Internal Revenue Service

Your first name and initial

Last name

Your U.S. taxpayer identification number, if any

Fill in your

Address in country of residence

Address in the United States

addresses only if

you are filing this

form by itself and

not with your tax

return

Part I

General Information

1a Type of U.S. visa (for example, F, J, M, Q, etc.) and date you entered the United States

b Current nonimmigrant status and date of change (see instructions)

Of what country were you a citizen during the tax year?

3a What country issued you a passport?

Unlike the page 5 of Form 1040NR, these are the real number

b Enter your passport number

of days you were physically in the US during the year

4a Enter the actual number of days you were present in the United States during:

2016

2015

2014

b Enter the number of days in 2016 you claim you can exclude for purposes of the substantial presence test

Part II

Teachers and Trainees

For teachers, enter the name, address, and telephone number of the academic institution where you taught in 2016

For trainees, enter the name, address, and telephone number of the director of the academic or other specialized program

you participated in during 2016

Enter the type of U.S. visa (J or Q) you held during:

2010

2011

. If the type of visa you held during any

2012

2013

2014

2015

of these years changed, attach a statement showing the new visa type and the date it was acquired.

Were you present in the United States as a teacher, trainee, or student for any part of 2 of the 6 prior

calendar years (2010 through 2015)? .

Yes

If you checked the “Yes” box on line 8, you cannot exclude days of presence as a teacher or trainee unless

you meet the Exception explained in the instructions.

Part III

Students

Enter the name, address, and telephone number of the academic institution you attended during 2016

Enter the name, address, and telephone number of the director of the academic or other specialized program you participated

in during 2016

Enter the type of U.S. visa (F, J, M, or Q) you held during:

2010

2011

. If the type of visa you held during any

2012

2013

2014

2015

of these years changed, attach a statement showing the new visa type and the date it was acquired.

Were you present in the United States as a teacher, trainee, or student for any part of more than 5 calendar

years? .

Yes

If you checked the “Yes” box on line 12, you must provide sufficient facts on an attached statement to

establish that you do not intend to reside permanently in the United States.

During 2016, did you apply for, or take other affirmative steps to apply for, lawful permanent resident status

in the United States or have an application pending to change your status to that of a lawful permanent

resident of the United States? .

Yes

If you checked the “Yes” box on line 13, explain

8843

For Paperwork Reduction Act Notice, see page 4.

Form

(2016)

Cat. No. 17227H

Form 8843 Draft - Statement For Exempt Individuals And Individuals With A Medical Condition - 2016

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