Form 13614-NR (October 2020) Nonresident Alien Intake and
Transcript Of Form 13614-NR (October 2020) Nonresident Alien Intake and
Form 13614-NR
(October 2021)
Department of the Treasury - Internal Revenue Service
Nonresident Alien Intake and Interview Sheet
OMB Number 1545-2075
Last or Family Name
First
Middle Initial
ITIN or Social Security #
Visa #
Passport #
Date of Birth: (mm/dd/yyyy)
/
/
Telephone #
e-mail Address
Were you a U.S. citizen or resident alien the entire year? Yes
No Were you ever a U.S. citizen?
Yes
No
U.S. Local Street Address
City
State
Zip Code
Foreign Residence Address
Address Line 2
Foreign Country
Province/County
Postal Code
Country of Citizenship
Country that issued Passport
Are you married?
Yes
No
If “YES”, is your spouse in the U.S.?
Yes
No
If "YES", is it recognized by the State where you will be filing? Yes
No
Are you a
U.S. National Yes No
Resident of Canada
Yes No
Resident of Mexico
Yes No
Resident of South Korea
Yes No
Resident of India
Yes
No
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. in 2021
U.S. citizen, U.S. resident
alien, U.S. national, or a resident of Canada, Mexico, or South Korea
Did person Did you provide provide
Did more than more than person file 50% of 50% of
joint their own their return? support? support?
Did the person have Gross Income of $4,300 or more?
What is the date you FIRST entered the United States?
/
/
Were you prevented from exiting the U.S. due to COVID-19, Emergency Travel Disruptions on or after 2-1-2020 and Yes No before 4-2-2020? (This may affect the substantial presence test)
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
Other (list)
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
Other (list)
Have you ever changed your visa type or U.S. immigration status?
Yes
No
If “Yes”, indicate the date and nature of the change.
/
/
Enter the type of U.S. visa you held during these years
2015
2016
2017
2018
2019
2020
* If Immigration status is J-1, what is the subtype? Check one
01 Student
05 Professor
02 Short Term Scholar
Other (list)
What is the actual primary activity of the visit? Check one
12 Research Scholar
01 Studying in a Degree Program 02 Studying in a Non-Degree Program 03 Teaching
04 Lecturing 05 Observing 06 Consulting
07 Conducting Research 08 Training 09 Demonstrating Special Skills
10 Clinical Activities 11 Temporary Employment 12 Here with Spouse
Catalog Number 39748B
www.irs.gov
Form 13614-NR (Rev. 10-2021)
Check the years you were present in the United States as a teacher, trainee, student or as an accompanying spouse or
dependent of a person in such status for any part of the year.
2015
2016
2017
2018
2019
2020
Have you ever been present in the U.S. PRIOR to 2015 on a teacher, trainee, student visa, or as their accompanying spouse or dependent? Yes No If so, what years and visa type
How many days (including vacations, nonworkdays and partial days) were you present in the U.S. during
2019
2020
2021
List the dates you entered and left the United States during 2021
Date entered United States Date departed United States
mm/dd/yyyy
mm/dd/yyyy
Date entered United States Date departed United States
mm/dd/yyyy
mm/dd/yyyy
Did you file a U.S. income tax return for any year before 2021?
Yes
No
If “Yes”, give latest year
/
/
Form number filed
During 2021, did you apply to be a green card holder (lawful permanent resident) of the United States?
Yes
No
Do you have an application pending to change your status to lawful permanent resident?
Yes
No
1. Are you claiming the benefits of a U.S. income tax treaty with a foreign country?
Yes
No
If “Yes”, enter the appropriate information in the columns below
(a) Country
(b) Tax Treaty Article
(c) Number of months (d) Amount of exempt claimed in prior tax years 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?
Yes
No
Information about academic institution you attended in 2021
Name
Telephone number
Address
Name of your academic/specialized program director
Telephone number
Address
During 2021 did you receive
Did you have
Scholarships or Fellowship Grants Wages, Salaries or Tips
Yes No Casualty Losses in a Declared Disaster
Yes No Area
Yes No
Interest
Yes No Student Loan Interest Paid
Yes No
Distributions from IRA, Pension or Annuity State or Local Tax Refunds
Yes No State or Local Income Taxes Yes No U.S. Charitable Contributions
Yes No Yes No
Unemployment Compensation
Yes No Child/Dependent Care Expenses
Yes No
Dividend income or capital gains or losses
Yes No IRA Contributions
Yes No
Any Other Income (gambling, lottery, prizes, awards, self-employment, rents, royalties, virtual currency, etc.)
Yes No
Did you or any dependent have health insurance coverage through HealthCare.gov (The Marketplace)?
Yes No
If yes, was any Advanced Premium Tax Credit received? (Provide Form 1095-A) Privacy Act and Paperwork Reduction Act Notice
Yes No
The Privacy Act of 1974 requires that when we ask for information we tell you our legal right to ask for the information, why we are asking for it, and how it will be used. We must also tell you what could happen if we do not receive it, and whether your response is voluntary, required to obtain a benefit, or mandatory.
Our legal right to ask for information is 5 U.S.C. 301. We are asking for this information to assist us in contacting you relative to your interest and/or participation in the IRS volunteer income tax preparation and outreach programs. The information you provide may be furnished to others who coordinate activities and staffing at volunteer return preparation sites or outreach activities. The information may also be used to establish effective controls, send correspondence and recognize volunteers. Your response is voluntary. However, if you do not provide the requested information, the IRS may not be able to use your assistance in these programs.
The Paperwork Reduction Act requires that the IRS display an OMB control number on all public information requests. The OMB Control Number for this study is 1545-2075. Also, if you have any comments regarding the time estimates associated with this study or suggestion on making this process simpler, please write to the Internal Revenue Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, Washington, DC 20224.
Catalog Number 39748B
www.irs.gov
Form 13614-NR (Rev. 10-2021)
(October 2021)
Department of the Treasury - Internal Revenue Service
Nonresident Alien Intake and Interview Sheet
OMB Number 1545-2075
Last or Family Name
First
Middle Initial
ITIN or Social Security #
Visa #
Passport #
Date of Birth: (mm/dd/yyyy)
/
/
Telephone #
e-mail Address
Were you a U.S. citizen or resident alien the entire year? Yes
No Were you ever a U.S. citizen?
Yes
No
U.S. Local Street Address
City
State
Zip Code
Foreign Residence Address
Address Line 2
Foreign Country
Province/County
Postal Code
Country of Citizenship
Country that issued Passport
Are you married?
Yes
No
If “YES”, is your spouse in the U.S.?
Yes
No
If "YES", is it recognized by the State where you will be filing? Yes
No
Are you a
U.S. National Yes No
Resident of Canada
Yes No
Resident of Mexico
Yes No
Resident of South Korea
Yes No
Resident of India
Yes
No
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. in 2021
U.S. citizen, U.S. resident
alien, U.S. national, or a resident of Canada, Mexico, or South Korea
Did person Did you provide provide
Did more than more than person file 50% of 50% of
joint their own their return? support? support?
Did the person have Gross Income of $4,300 or more?
What is the date you FIRST entered the United States?
/
/
Were you prevented from exiting the U.S. due to COVID-19, Emergency Travel Disruptions on or after 2-1-2020 and Yes No before 4-2-2020? (This may affect the substantial presence test)
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
Other (list)
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
Other (list)
Have you ever changed your visa type or U.S. immigration status?
Yes
No
If “Yes”, indicate the date and nature of the change.
/
/
Enter the type of U.S. visa you held during these years
2015
2016
2017
2018
2019
2020
* If Immigration status is J-1, what is the subtype? Check one
01 Student
05 Professor
02 Short Term Scholar
Other (list)
What is the actual primary activity of the visit? Check one
12 Research Scholar
01 Studying in a Degree Program 02 Studying in a Non-Degree Program 03 Teaching
04 Lecturing 05 Observing 06 Consulting
07 Conducting Research 08 Training 09 Demonstrating Special Skills
10 Clinical Activities 11 Temporary Employment 12 Here with Spouse
Catalog Number 39748B
www.irs.gov
Form 13614-NR (Rev. 10-2021)
Check the years you were present in the United States as a teacher, trainee, student or as an accompanying spouse or
dependent of a person in such status for any part of the year.
2015
2016
2017
2018
2019
2020
Have you ever been present in the U.S. PRIOR to 2015 on a teacher, trainee, student visa, or as their accompanying spouse or dependent? Yes No If so, what years and visa type
How many days (including vacations, nonworkdays and partial days) were you present in the U.S. during
2019
2020
2021
List the dates you entered and left the United States during 2021
Date entered United States Date departed United States
mm/dd/yyyy
mm/dd/yyyy
Date entered United States Date departed United States
mm/dd/yyyy
mm/dd/yyyy
Did you file a U.S. income tax return for any year before 2021?
Yes
No
If “Yes”, give latest year
/
/
Form number filed
During 2021, did you apply to be a green card holder (lawful permanent resident) of the United States?
Yes
No
Do you have an application pending to change your status to lawful permanent resident?
Yes
No
1. Are you claiming the benefits of a U.S. income tax treaty with a foreign country?
Yes
No
If “Yes”, enter the appropriate information in the columns below
(a) Country
(b) Tax Treaty Article
(c) Number of months (d) Amount of exempt claimed in prior tax years 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?
Yes
No
Information about academic institution you attended in 2021
Name
Telephone number
Address
Name of your academic/specialized program director
Telephone number
Address
During 2021 did you receive
Did you have
Scholarships or Fellowship Grants Wages, Salaries or Tips
Yes No Casualty Losses in a Declared Disaster
Yes No Area
Yes No
Interest
Yes No Student Loan Interest Paid
Yes No
Distributions from IRA, Pension or Annuity State or Local Tax Refunds
Yes No State or Local Income Taxes Yes No U.S. Charitable Contributions
Yes No Yes No
Unemployment Compensation
Yes No Child/Dependent Care Expenses
Yes No
Dividend income or capital gains or losses
Yes No IRA Contributions
Yes No
Any Other Income (gambling, lottery, prizes, awards, self-employment, rents, royalties, virtual currency, etc.)
Yes No
Did you or any dependent have health insurance coverage through HealthCare.gov (The Marketplace)?
Yes No
If yes, was any Advanced Premium Tax Credit received? (Provide Form 1095-A) Privacy Act and Paperwork Reduction Act Notice
Yes No
The Privacy Act of 1974 requires that when we ask for information we tell you our legal right to ask for the information, why we are asking for it, and how it will be used. We must also tell you what could happen if we do not receive it, and whether your response is voluntary, required to obtain a benefit, or mandatory.
Our legal right to ask for information is 5 U.S.C. 301. We are asking for this information to assist us in contacting you relative to your interest and/or participation in the IRS volunteer income tax preparation and outreach programs. The information you provide may be furnished to others who coordinate activities and staffing at volunteer return preparation sites or outreach activities. The information may also be used to establish effective controls, send correspondence and recognize volunteers. Your response is voluntary. However, if you do not provide the requested information, the IRS may not be able to use your assistance in these programs.
The Paperwork Reduction Act requires that the IRS display an OMB control number on all public information requests. The OMB Control Number for this study is 1545-2075. Also, if you have any comments regarding the time estimates associated with this study or suggestion on making this process simpler, please write to the Internal Revenue Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, Washington, DC 20224.
Catalog Number 39748B
www.irs.gov
Form 13614-NR (Rev. 10-2021)