Free Form 13614-NR (Rev. 8-2008) - Federal

Form 13614NR (Rev. 8-2008)

Nonresident Alien Intake and Interview Sheet
First: Visa #: Passport #:

OMB# 1545-2075 Middle Initial:

Last or Family Name: ITIN or Social Security #: Date of Birth:
(mm/dd/yyyy)

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Telephone #:

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Yes No

e-mail Address: Were you ever a U.S. citizen? Yes No

Are you a U.S. citizen or resident alien all year? U.S. Local Street Address: City: Foreign Residence Address: Address Line 2: Postal Code: Country of Citizenship: Are you married? Are you a: U.S.National Yes Yes No No Province/Region:

State:

Zip Code:

Foreign Country: Country that issued Passport:

If YES, is your spouse in the U.S.? Yes No No Resident of Mexico

Yes Yes No

No Resident of Republic of Korea Yes Yes No No
Did the person have Gross Income of $3500 or more?

Resident of Canada Yes

Do you have dependents? Dependent Information

If YES, how many?

Are they in the United States?

First Name

Last Name

Date of Birth (mm/dd/yyyy)

ITIN or SSN

Relationship to you

U.S. Citizen, National, Did Resident of person Months Canada, Mexico, file joint in U.S. Republic of Korea return?

Did you Did child provide provide more than more than 50% of 50% of their their own support? support?

What is the date you FIRST entered the United States? Entry Immigration Status - Check one: U.S. Immigrant/Permanent Resident H-1 Temporary Employee Other: (List) Current Immigration Status - Check one: U.S. Immigrant/Permanent Resident H-1 Temporary Employee Other: (List) On what date did your visa type change?

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F-2 Spouse or child of Exchange Visitor J-2 Spouse or child of Exchange Visitor

F-1 Student J-1 Exchange Visitor

F-1 Student J-1 Exchange Visitor

F-2 Spouse or child of Exchange Visitor J-2 Spouse or child of Exchange Visitor

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2005 2006 12 Research Scholar 2007

Enter the type of U.S. visa you held during these years: 2002 2003 2004 05 Professor Other: (List) 04 Lecturing 05 Observing 06 Consulting If Immigration status is J-1, what is the subtype? Check one: 01 Student 02 Short Term Scholar

What is the actual primary activity of the visit? Check one: 01 Studying in a Degree Program 02 Studying in a Non-Degree Program 03 Teaching
Form 13614NR (Rev. 8-2008)

07 Conducting Research 08 Training 09 Demonstrating Special Skills

10 Clinical Activities 11 Temporary Employment 12 Here with Spouse

Catalog Number 39748B

Department of the Treasury -- Internal Revenue Service

Were you present in the United States as a teacher, trainee or student for any part of 2 of the 6 prior calendar years? 2002 2003 2004 2005 2006 2007 Yes No Were you present in the U.S. as a teacher, trainee or student for any part of more than 5 calendar years? How many days were you present in the U.S. during 2006 2007 2008

List the dates you entered and left the United States during 2008:

Did you file a U.S. income tax return for any year before 2008?

Yes

No If "Yes", when

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What form?

During 2008, did you apply for or take affirmative steps to apply for lawful permanent resident status in the United States? Yes No Do you have an application pending to change your status to lawful permanent resident? Are you claiming treaty benefits? Treaty Article Number: Type & Amount of Income: Information about academic institution you attended in 2008 Name: Address: Name of the director of your specialized program: Address: Telephone Number: Telephone Number: Yes No If Yes, What country Yes No

During 2008 did you receive:
Scholarships or Fellowship Grants Wages, Salaries or Tips Interest or Dividend Income Distributions from IRA, Pension or Annuity Business Income Unemployment Compensation Gambling Winnings Any Other Income
Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No

Did you have:
Casualty or Theft Losses Student Loan Interest State or Local Income Taxes Charitable Contributions Moving Expenses Business Expenses Child/Dependent Care Expenses IRA Deductions
Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No

Form 13614NR (Rev. 8-2008)

Catalog Number 39748B

Department of the Treasury -- Internal Revenue Service