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As565 (Louisiana State University)

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Louisiana State University
Office of Accounting Services
Payroll
204 Thomas Boyd Hall
ALIEN TAX INFORMATION REQUEST (ATAX) AS565
S
ee instuctions on the back of this form.
All non-US citizens who receive compensation from LSU must complete this form. To ensure correct determination of your tax status, all applicable
questions below must be answered and a copy of the following documents must be attached: Unexpired passport; 1-94 Form “Arrival and
Departure Record” (a small white card inside your passport); U.S. Visa from your passport; and I-20, IAP66, DS2019, or I-797 (H1-B).
SECTION A: PERSONAL INFORMATION
1. First Name 2. Middle 3. Last Name
4. LSUID or ITIN 5. Date of Birth
6. Street Address
7. City 8. State 9. Zip
SECTION B: STUDENT INFORMATION
1. Name of Academic Department 2. Are you a student? Yes No
3. If you have attended or currently are attending another U.S. educational institution, provide:
Name of Educational Institution ________________________________________________
Period of Attendance: From ______________________ to __________________________
Degree Granted (if any): _____________________________________________________
4.
Did you receive Tax Treaty benefits at
another U.S. educational institution during t
he
c
urrent year
?
Yes No
SECTION C: IMMIGRATION & ALIEN TAX INFORMATION
(Permanent Residents with Green Cards may skip Section C as long as a copy of documentation is provided)
1. Date of 1
st
U.S. Entry 2a. Visa Type upon U.S. Entry 2b. Visa type of the primary Visa holder? (Ex: Student, Non-student, etc.)
3. Current Visa Type (check appropriate box)
F-1 Student F-1 Student (on Practical Training) F-2 Spouse/Dependent of F-1 H-1 Distinguished Worker
J-1 Student J-1 Student (on “Academic Training”) J-2 Spouse/Dependent of J-1 Student TN- NAFTA Free Trade
Other J-1 Visitor: Other INS Classification (list status)
Short-term scholar _________________________________
Professor U.S. Permanent Resident (must provide documentation)
Research Scholar
Other________________________________
4. Country of Birth 5. Country of Citizenship 6. Country of Residence (for tax purposes)
7. Furnish the requested information to detail the number of days you were physically present in the United States during the calendar year listed
below. Note: The term “calendar year” refers to the period January 1 to December 31.
Calendar
Year
Number of Days
present in the U.S.
during the year
Date of Entry Date of Exit Visa
J-1 Sub Type
(if applicable)
Did you receive
Tax Treaty
benefits?
Current Calendar
Yes No
Last Calendar Year
Yes No
Two (2) years ago
Yes No
Three (3) years ago
Yes No
Four (4) years ago
Yes No
Five (5) years ago
Yes No
Six (6) years ago
Yes No
8. Residence for Tax Purposes Under IRS definitions, for tax purposes I am considered a Resident Alien Nonresident Alien
SECTION D: CERTIFICATION OF INFORMATION
I certify to the best of my knowledge, all of the information I have provided above is true, correct and complete. Also, I understand it is my
responsibility to keep my employment authorization documents (including passport, IAP-66, I-20, I-688B, DS2019, or other INS employment
authorization) current (unexpired) at all times. To avoid being removed from the University payroll, I will inform Payroll of any extensions,
renewals, or changes in status by completing an I-9 form in the International Services Office by the expiration of the employment
documentation.
Signature ____________________________________________________ Date ______________________________
Rev 07/07
AS565, “ALIEN TAX INFORMATION REQUEST (ATAX)”
INSTRUCTIONS
The AS565, “Alien Tax Information Request”, must be completed because you are receiving income from the University.
Since the tax withholding requirements are different for resident aliens and nonresident aliens, it is essential to establish
the residency status of non U.S. citizens. Therefore, this form must be complete annually to assist us the Payroll Office in
determining whether you should be classified for federal tax withholding purposes as a resident alien or a nonresident
alien. The instructions below will assist you in completing the AS565. Other questions can be directed to the Payroll
Office by calling 578-4844.
Section A – Personal Information
1 – 3. Enter your full name: First Name, Middle, Last Name
4. Enter your LSUID number or your Individual Taxpayer Identification Number (ITIN). All employees must have a
U.S. Social Security Number (SSN) in order to work. You will not receive payment until an SSN is obtained and
reported to the Payroll Office. Individuals ineligible for a SSN may apply for an ITIN by filing form W-7, along with
necessary documentation, in the Payroll Office.
5. Enter your Date of Birth
6 - 9. Enter your local address - Street Address, City, State, Zip
Section B – Student Information
1. Enter the name of the department where you are studying or working.
2. Indicate whether or not you are a student by checking the appropriate box.
3. Indicate whether or not you are currently attending or have previously attended another U.S. educational
institution and the dates of attendance. Indicate any degree you may have already received.
4. Indicate whether or not you have previously received Tax Treaty benefits during the current year at another
institution by checking the appropriate box.
Section C – Immigration & Alien Tax Information
1. Enter the calendar date on which you entered the U.S. for the first time. You must include the month, day and
year. If you are uncertain, approximate the date.
2a. Enter the Visa type you held when you first entered the U.S.
2b. If you entered on a Spouse/Dependent Visa, enter the Visa type of the primary Visa holder.
3. Indicate your current Visa type by checking the appropriate box.
4. Enter the name of the country where you were born.
5. Enter the name of the country of your citizenship.
6. Enter the name of the country of which you are a tax resident.
7. Complete each row and column in this chart. For each year, enter the Visa type(s) under which you were
present. If you were present under several Visas during the same calendar year, enter all of the Visas. Enter the
total days of U.S. presence for each calendar year; this total should include all days of presence under all Visa
types. For the current year, estimate to the best of your ability the exact number of days you will be present in the
U.S. Also indicate if you received Tax Treaty benefits during any of these periods.
8. Indicate if you are a resident alien or nonresident alien for tax purposes by checking the appropriate box.
Section D – Certification of Information
Sign and date
Return to the Office of Accounting Services, Payroll division, 204 Thomas Boyd Hall, as soon as possible.
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Completed 21 July 2020

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