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International Information Form

3415 FR.01 -

& Substitute IRS Form W-8 BEN

B. S

2: S

TEP

UBSTANTIAL PRESENCE TEST

The Substantial Presence Test involves a calculation of the number of days that you have been physically present in the U.S.

For purposes of this calculation, DO NOT include in your calculation any days that you are or were present in the U.S. as:

• A Student, or dependent of a Student, on an F or J category visa (during the first five calendar years that you are/were present in the U.S.)

• A Professor or Research Scholar or dependent of a Professor or Research Scholar on a J category visa (during the first two calendar years of the past six

calendar years that you are/were present in the U.S.)

Example: If you arrived in the U.S. for the first time on August 15, 1995 as a J-1 research scholar and you have been in the U.S. since that date, do not include in

your calculation the days that you are or were present in the U.S. for the first two calendar years (1995 and 1996). For this example, you would begin to

count the number of days present in the U.S. from January 1, 1997 until the present.

Example: If you arrived in the U.S. for the first time on September 1, 1993, as an F-1 student and you have been in the U.S. since that date, do not include in your

calculation the days that you are or were present in the U.S. for the first five calendar years (1993, 1994, 1995, 1996 and 1997). For this example, you

would begin to count the number of days present in the U.S. form January 1, 1998, until the present.

Note: If you have no days in a calendar year to include in your calculations, enter a “0” (zero) on the line for “Number of Days in U.S.”

CALCULATION FOR SUBSTANTIAL

YEAR

NUMBER OF DAYS IN U.S.

PRESENCE

Current Year

1/3

Preceding Year

1/6

Preceding Year

TOTAL: ______________

As of the date you completed this form:

•

if the Total is less than 183 you are a NONRESIDENT ALIEN for tax purposes.

•

if the Total is equal to or greater than 183 you are a RESIDENT ALIEN for tax purposes.

C. S

U.S.

UMMARY OF RESIDENCY STATUS FOR

TAX PURPOSES

I certify that I am a lawful PERMANENT RESIDENT or IMMIGRANT ALIEN.

I certify that I am a RESIDENT ALIEN for tax purposes.

I certify that I am a NONRESIDENT ALIEN for tax purposes; I am the beneficial owner of all of the income to which this form relates; This income

is not effectively connected with the conduct of a trade or business in the U.S.; and I am not a former citizen or long-term resident of the United States

subject to section 877 (relating to certain acts of repatriation) or, if I am subject to Section 877, I am nevertheless entitled to treaty benefits with respect to

amounts received. Failure to complete any required additional forms will result in the automatic withholding of tax at the maximum rates.

I declare under penalties of perjury that the information provided above is true and correct. If I receive an extension of my visa status or if my

visa/immigration status changes, I will notify the Tax Department at (203) 432-5530 immediately.

The Internal Revenue Service does not require your consent to any provisions of this document other than the certifications required to establish your

status as a foreign person, and, if applicable, obtain a reduced rate of withholding.

Signature:_____________________________________________________ Local Phone Number: _____________________ Date: ____________

FOR TAX DEPARTMENT USE ONLY:

Residency Status

Residency Status Change Date

Tax

Tax Treaty Expiration Date

Dollar Limit

FICA Expiration

Approval/Date

Rate

Date