Form 13614nr - Nonresident Alien Intake And Interview Sheet Page 2
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1
2What 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
Check the years you were present in the United States as a teacher, trainee, or student for any part of the year.
2006
2007
2008
2009
2010
2011
Were you present in the U.S. as a teacher, trainee or student for any part of more than any 5 calendar years?
Yes
No
How many days (including vacations, nonworkdays and partial days) were you present in the U.S. during:
2010
2011
2012
List the dates you entered and left the United States during 2012:
Date entered United States
Date departed United States
Date entered United States
Date departed United States
mm/dd/yyyy
mm/dd/yyyy
mm/dd/yyyy
mm/dd/yyyy
Did you file a U.S. income tax return for any year before 2012?
Yes
No
If “Yes”, give latest year
/
/
Form number filed
During 2012, did you apply to be a green card holder (lawful permanent resident) of the United States?
Yes
No
Do you have an application pending to change your status to lawful permanent resident?
Yes
No
1. Are you claiming the benefits of a U.S. income tax treaty with a foreign country?
Yes
No
If “Yes”, enter the appropriate information in the columns below:
(c) Number of months
(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
No
Information about academic institution you attended in 2012
Name:
Telephone Number:
Address:
Name of the director of your academic or specialized program:
Address:
Telephone Number:
During 2012 did you receive:
Did you have:
Casualty or Theft Losses
Yes
No
Yes
No
Scholarships or Fellowship Grants
Wages, Salaries or Tips
Student Loan Interest
Yes
No
Yes
No
State or Local Income Taxes
Interest or Dividend Income
Yes
No
Yes
No
Distributions from IRA, Pension or
Charitable Contributions
Yes
No
Yes
No
Annuity
Business Income
Moving Expenses
Yes
No
Yes
No
Unemployment Compensation
Business Expenses
Yes
No
Yes
No
Capital gains or losses
Yes
Child/Dependent Care Expenses
No
Yes
No
Any Other Income
IRA Contributions
Yes
No
Yes
No
(gambling, lottery, prizes, awards, rents, royalties, etc.)
13614NR
Form
(Rev.
)
Catalog Number 39748B
Department of the Treasury — Internal Revenue Service
10-20121
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