Form 13614-NR (October 2020) Nonresident Alien Intake and

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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)
ResidentChildCheckPersonList