Form 13614-NR Nonresident Alien Intake and Interview Sheet

Form 13614NR
(Rev. 10-2006)

NONRESIDENT ALIEN INTAKE AND INTERVIEW SHEET

Last or Family Name:

First:

Middle Initial:

Visa #:

Social Security #:
Date of Birth:

Pilot 2006

/

/

Passport #:

Telephone #: Daytime:

Are you a U.S. citizen or resident alien all year?

Evening:

Yes

Were you ever a U.S. citizen?

No

Yes

No

U.S. Local Street Address:
City:

State:

Zip Code:

Foreign Residence Address:
Address Line 2:
Postal Code:

Province/Region:

Foreign Country:

Country of Citizenship:
Are you married?
Are you a:
U.S.National

Country that issued Passport:
Yes

Yes

No

Do you have dependents?

No

If YES, is your spouse in the U.S.?

Resident
of Canada
Yes

Yes

Resident
of Mexico

No

Yes

If YES, how many?

No

Yes

No
No

Resident of
Republic of Korea

Are they in the United States?

Yes
Yes

No
No

Dependent Information

First Name

Date of Birth

Last Name

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

Relationship
to you

/

What is the date you FIRST entered the United States?

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

Did the
person
have
Gross
Income
of $3300
or more?

/

Entry Immigration Status - Check one:
U.S. Immigrant/Permanent Resident
J-1 Exchange visitor
Other: (List)

F-1 Student
H-1 Temporary Employee

F-2 Spouse or child of exchange visitor
J-2 Spouse or child of exchange visitor

F-1 Student
H-1 Temporary Employee

F-2 Spouse or child of exchange visitor
J-2 Spouse or child of exchange visitor

Current Immigration Status - Check one:
U.S. Immigrant/Permanent Resident
J-1 Exchange visitor
Other: (List)

/

On what date did your visa type change?

/

Enter the type of U.S. visa you held during these years:
2000

2001

2002

2003

2004

2005

If Immigration status is J-1, what is the subtype? Check one:
01 Student
02 Short Term Scholar

05 Professor
Other: (List)

12 Research 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

04 Lecturing
05 Observing

07 Conducting Research
08 Training

10 Clinical Activities
11 Temporary Employment

03 Teaching

06 Consulting

09 Demonstrating Special Skills

12 Here with Spouse

Form 13614NR (Rev. 10-2006)

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?
2000

2001

2002

2003

2004

2005

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

2004

Yes

No

2006

2005

List the dates you entered and left the United States during 2006:

Did you file a U.S. income tax return for any year before 2006?

Yes

No If “Yes”, when

/

What form?

/

During 2006, 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?

Yes

No

Yes

No

If Yes, What country

Treaty Article Number:
Type & Amount of Income:
Information about academic institution you attended in 2006
Name:

Telephone Number:

Address:
Name of the director of your specialized program:
Address:
Telephone Number:

During 2006 did you receive:

Did you have:

Scholarships or Fellowship grants

Yes

No

Charitable Contributions

Yes

No

Wages, salaries or tips

Yes

No

Moving Expenses

Yes

No

Interest or dividend income

Yes

No

Business Expenses

Yes

No

Distributions from IRA, pension or
annuity

Yes

No

Child/Dependent care expenses

Yes

No

Business Income

Yes

No

IRA Contributions

Yes

No

Unemployment Compensation

Yes

No

Gambling Winnings

Yes

No

Any other type of income

Yes

No

Form 13614NR (Rev. 10-2006)

Catalog Number 39748B

Department of the Treasury — Internal Revenue Service