Form 8843 - Statement For Exempt Individuals And Individuals With A Medical Condition - 2012
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48843
Statement for Exempt Individuals and Individuals
OMB No. 1545-0074
With a Medical Condition
2012
Form
For use by alien individuals only.
Information about Form 8843 and its instructions is at
▶
Attachment
102
For the year January 1—December 31, 2012, or other tax year
Sequence No.
Department of the Treasury
beginning
, 2012, 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?
2
3a What country issued you a passport?
b Enter your passport number
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4a Enter the actual number of days you were present in the United States during:
2012
2011
2010
b Enter the number of days in 2012 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 2012
5
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6
For trainees, enter the name, address, and telephone number of the director of the academic or other specialized program
you participated in during 2012
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7
Enter the type of U.S. visa (J or Q) you held during:
2006
2007
▶
. If the type of visa you held during any
2008
2009
2010
2011
of these years changed, attach a statement showing the new visa type and the date it was acquired.
8
Were you present in the United States as a teacher, trainee, or student for any part of 2 of the 6 prior
Yes
No
calendar years (2006 through 2011)? .
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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
9
Enter the name, address, and telephone number of the academic institution you attended during 2012
▶
10
Enter the name, address, and telephone number of the director of the academic or other specialized program you participated
in during 2012
▶
11
Enter the type of U.S. visa (F, J, M, or Q) you held during:
2006
2007
▶
. If the type of visa you held during any
2008
2009
2010
2011
of these years changed, attach a statement showing the new visa type and the date it was acquired.
12
Were you present in the United States as a teacher, trainee, or student for any part of more than 5 calendar
years? .
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Yes
No
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.
13
During 2012, 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? .
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Yes
No
If you checked the “Yes” box on line 13, explain
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8843
For Paperwork Reduction Act Notice, see page 4.
Form
(2012)
Cat. No. 17227H
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