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International Information Form

3415 FR.01 -

& Substitute IRS Form W-8 BEN

All applicable questions below must be answered. Attach to this form a copy of both sides of your I-94 Form, “Arrival and Departure Record” (a small white or

green card inside your passport), a copy of your U.S. visa from your passport, and I-20 or IAP66, if applicable. This form must be returned before the University can

issue any check. Address all questions regarding this form to the Yale University Tax Department at (203) 432-5530.

SECTION 1

Last (Family) Name:______________________________________________ First: ______________________________Middle: ________________

Social Security # or ITIN: _________________________________________

WS ID# ____________________________________(for office use only)

(This field generally cannot be left blank. Please see instructions for

exception to this requirement.)

U.S. LOCAL STREET ADDRESS:____________________________

FOREIGN RESIDENCE ADDRESS: _______________________________

________________________________________________________

______________________________________________________________

Address Line 2: ___________________________________________

Address Line 2: _________________________________________________

Address Line 3: ___________________________________________

Address Line 3/City: _____________________________________________

City: ____________________________________________________

Postal Code:_______________________ Province/Region: ______________

State:________ Zip:_________________

Foreign Country: ________________________________________________

Type of Beneficial Owner:

ndividual

Corporation

Disregarded Entity

Partnership

Trus

Estate

Foreign Government

International Organization

Foreign central bank of issue

Foreign tax-exempt organization

Country of Citizenship: ___________________________________________ Country Issuing Passport:____________________________________________

Passport #: _____________________________________________________ Visa #: ___________________________________________

(number printed in red)

Have you ever been in the United States prior to this visit?

Yes

No If yes, see page 2., section 5.

U RENT IMMIGRATION STATUS

U.S. Immigrant/Permanent Resident

B-1 Visitor for Business

WB Visitor for Business (visa waiver)

F-1 Student

H-1B Temporary Employee

B-2 Visitor for leasure

WT Visitor for Pleasure (visa waiver)

J-1 Exchange Visitor

J-2 Spouse or Child of Exchange Visitor

O-1 Exceptional Ability

Other__________________________________

B-1, B-2, W

F CURRENT IMMIGRATION STATUS IS

The number of days that academic activities will be performed at Yale University during this visit on current immigration status:_______________

Are you receiving:

an honorarium or other payment for services; OR

an honorarium or other payment for services plus reimbursement for expenses;

reimbursement of expenses ONLY from Yale University for this visit?

Have you accepted honoraria and/or reimbursement for expenses, from more than 5 U.S. institutions or organizations in the last 6 months in the U.S.?

Yes

SECTION 2: Complete if immigration status is not B-1, B-2, WB or WT

* = non-Yale sponsorship

AT IS THE PRIMARY ACTIVITY OF THE VIS

CHECK ONE

Studying in a Degree Program

Observing

Demonstrating Special Skills

Performing as an Athlete *

Studying in a Non-Degree Program

Consulting

Clinical Activities

Performing as an Artist

Teaching

Conducting Research

Temporary Employment *

Supporting an Athlete/Artist

Lecturing

Acquiring Training *

Practical

Training

Here with Spouse

J-1,

F CURRENT IMMIGRATION STATUS IS

WHAT IS THE SUBTYPE

CHECK ONE

Student

Professor

Trainee *

Research Scholar

Alien Physician

Short Term Scholar ___

Other

SECTION 3: Answer all applicable questions

What is the actual date you entered the United States? (month/day/year) ____/____/______

Start date of your immigration status for this primary activity: ___/___/____ Projected end date of your immigration status for this primary activity? ___/____/___

What is your income-providing activit (e.g. professor of chemistry, guest lecturer, student)? _________________________________________________

What is your source of funding?

U.S.

Foreign

Do you have a spouse in the U.S.?

Yes

No If you have dependents, how many? __ _________________ _

If you are a student, what type?

Undergraduate

Masters

Doctoral

Other:_______________________