Fillable Form 13614-Nr - Nonresident Alien Intake And Interview Sheet (Page 2 of 2) in pdf

Check the years you were present in the United States as a teacher, trainee, student or as an accompanying spouse or

dependent of a person in such status for any part of the year.

2011

2012

2013

2014

2015

2016

Have you ever been present in the U.S. PRIOR to 2011 on a teacher, trainee, student visa, or as their accompanying spouse or

dependent?

Yes

If so, what years and visa type

How many days (including vacations, nonworkdays and partial days) were you present in the U.S. during:

2015

2016

2017

List the dates you entered and left the United States during 2017:

Date entered United States

Date departed United States

Date entered United States

Date departed United States

mm/dd/yyyy

Did you file a U.S. income tax return for any year before 2017?

Yes

If “Yes”, give latest year

Form number filed

During 2017, did you apply to be a green card holder (lawful permanent resident) of the United States?

Yes

Do you have an application pending to change your status to lawful permanent resident?

Yes

1. Are you claiming the benefits of a U.S. income tax treaty with a foreign country?

Yes

If “Yes”, enter the appropriate information in the columns below:

(d) Amount of exempt

(a) Country

(b) Tax Treaty Article

claimed in prior tax years

income in current tax year

2. Were you subject to tax in a foreign country on any of the income shown in 1(d) above?

Yes

Information about academic institution you attended in 2017

Name:

Telephone Number:

Address:

Name of the director of your academic or specialized program:

Address:

Telephone Number:

During 2017 did you receive:

Did you have:

Scholarships or Fellowship Grants

Yes

Casualty or Theft Losses

Yes

Wages, Salaries or Tips

Yes

Student Loan Interest Paid

Yes

Interest or Dividend Income

Yes

State or Local Income Taxes

Yes

Distributions from IRA, Pension or Annuity

Yes

U.S. Charitable Contributions

Yes

Business Income

Yes

Moving Expenses

Yes

Unemployment Compensation

Yes

Business Expenses

Yes

Capital gains or losses

Yes

Child/Dependent Care Expenses

Yes

Any Other Income

Yes

IRA Contributions

Yes

(gambling, lottery, prizes, awards, rents, royalties, etc.)

Did you or any dependent have health insurance coverage through HealthCare.gov (The Marketplace)?

Yes

Privacy Act and Paperwork Reduction Act Notice

The Privacy Act of 1974 requires that when we ask for information we tell you our legal right to ask for the information, why we are asking for it, and how it will be used. We

must also tell you what could happen if we do not receive it, and whether your response is voluntary, required to obtain a benefit, or mandatory.

Our legal right to ask for information is 5 U.S.C. 301. We are asking for this information to assist us in contacting you relative to your interest and/or participation in the IRS

volunteer income tax preparation and outreach programs. The information you provide may be furnished to others who coordinate activities and staffing at volunteer return

preparation sites or outreach activities. The information may also be used to establish effective controls, send correspondence and recognize volunteers. Your response is

voluntary. However, if you do not provide the requested information, the IRS may not be able to use your assistance in these programs.

The Paperwork Reduction Act requires that the IRS display an OMB control number on all public information requests. The OMB Control Number for this study is 1545-2075.

Also, if you have any comments regarding the time estimates associated with this study or suggestion on making this process simpler, please write to the Internal Revenue

Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, Washington, DC 20224.

13614-NR

Form

(Rev. 10-2017)

Catalog Number 39748B

Department of the Treasury — Internal Revenue Service