Form 13614nr - Nonresident Alien Intake And Interview Sheet
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213614NR
Form
Nonresident Alien Intake and Interview Sheet
OMB# 1545-2075
(Rev. 10-2012)
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
Yes
No
If “YES”, is your spouse in the U.S.?
Are you a:
U.S. National
Resident
Resident
Resident of
Resident of
of Canada
of Mexico
South Korea
India
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Dependent Information
Did the
U.S. citizen,
Did child
Did you
person
U.S. resident
provide
provide
have
alien,
Did
Relationship
U.S. national,
more than
more than
Gross
person
to you (son,
or a resident of
50% of
50% of
Income of
Months
file joint
Date of Birth
daughter,
their own
their
$3,800 or
Canada, Mexico,
return?
First Name
Last Name
ITIN or SSN
in U.S.
(mm/dd/yyyy)
none, etc.)
support?
support?
more?
or South Korea
/
/
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
*J-1 Exchange Visitor
J-2 Spouse or child of Exchange Visitor
H-1 Temporary Employee
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:
2006
2007
2008
2009
2010
2011
*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)
13614NR
Form
(Rev.
)
Catalog Number 39748B
10-2012
Department of the Treasury — Internal Revenue Service
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