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Nonresident Alien Intake and Interview Form

Last or Family Name:    First:    Middle Initial:   
ITIN or Social Security #:    Visa #:    Passport #:   
Date of Birth:    Telephone #:    e-mail Address:   
Were you a U.S. citizen or resident alien the entire year? YesNo Were you ever a U.S. citizen?YesNo
U.S. Local Street Address:
City:    State:    Zip Code:   
Foreign Residence Address:   
Address Line 2:   
Foreign Country:    Province/Country:    Postal Code:    Country of Citizenship:    Country that issued Passport:   
Are you married? YesNo
If “YES”, is your spouse in the U.S.? YesNo
If "YES", is it recognized by the State where you will be filing? YesNo
Are you a: U.S. National
YesNo		 Resident of Canada
YesNo		 Resident of Mexico
YesNo		 Resident of South Korea
YesNo		 Resident of India
YesNo
Dependent Information:
First Name: Last or Family Name Date of Birth
(mm/dd/yyyy)		 ITIN or SSN Relationship to you (son, daughter, none, etc.) Number of months lived with you in the U.S. U.S. citizen, U.S. residentalien, U.S. national, or a resident of Canada, Mexico, or South Korea Did person file joint return? Did child provide more than 50% of their own support? Did you provide more than 50% of their support? Did the person have Gross Income of $4,000 or more?
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
Current 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
Have you ever changed your visa type or U.S. immigration status?   YesNo
If “Yes”, indicate the date and nature of the change.  
Enter the type of U.S. visa you held during these years:
* If Immigration status is J-1, what is the subtype? Check one:
01 Student 05 Professor 12 Research Scholar 02 Short Term Scholar
What 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.
2013 2014 2015 2016 2017 2018 2019
Were you present in the U.S. on a teacher, trainee or student visa for any part of more than any 5 calendar years?      YesNo
How many days (including vacations, nonworkdays and partial days) were you present in the U.S. during:
List the dates you entered and left the United States during 2019:
Did you file a U.S. income tax return for any year before 2019?     YesNo
If “Yes”, give latest year MM/DD/YYYY
Form number filed
During 2019, did you apply to be a green card holder (lawful permanent resident) of the United States?     YesNo
Do you have an application pending to change your status to lawful permanent resident?      YesNo
1. Are you claiming the benefits of a U.S. income tax treaty with a foreign country?      YesNo
If “Yes”, enter the appropriate information in the columns below:
(a) Country (b) Tax Treaty Article (c) Number of months
claimed in prior tax years		 (d) Amount of exempt
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?      YesNo
Information about academic institution you attended in 2019:
Name of the director of your academic or specialized program:
Scholarships or Fellowship Grants YesNo
Wages, Salaries or Tips YesNo
Interest or Dividend Income YesNo
Distributions from IRA, Pension or Annuity YesNo
Business Income YesNo
Unemployment Compensation YesNo
Capital gains or losses YesNo
Any Other Income
(gambling, lottery, prizes, awards, rents, royalties, etc.)		 YesNo
Casualty or Theft Losses YesNo
Student Loan Interest Paid YesNo
State or Local Income Taxes YesNo
U.S. Charitable Contributions YesNo
Moving Expenses YesNo
Business Expenses YesNo
Child/Dependent Care Expenses YesNo
IRA Contributions YesNo
I would like for my refund and/or payment owed to be refunded / deducted for the following bank account:
Name of Bank:
Checking Account #
Saving Account #
Routing #
Signature of Taxpayer:
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