Catalog Number 39748B
13614-NR (Rev. 10-2020)
Form 13614-NR
(October 2020)
Department of the Treasury - Internal Revenue Service
Nonresident Alien Intake and Interview Sheet
OMB Number
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? 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
Yes No
Resident of
Yes No
Resident of
South Korea
Yes No
Resident of
Yes No
Dependent Information
First Name
Last or
Family Name
Date of Birth
(mm/dd/yyyy) ITIN or SSN
to you (son,
none, etc.)
Number of
lived with
you in the
U.S. in
U.S. citizen,
U.S. resident
U.S. national,
or a resident of
Canada, Mexico,
or South Korea
person file
Did person
more than
50% of
their own
Did you
more than
50% of
Did the
Income of
$4,300 or
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
before 4-2-2020?
Yes No
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
2014 2015 2016 2017 2018
* If Immigration status is J-1, what is the subtype? Check one
01 Student
02 Short Term Scholar
05 Professor 12 Research Scholar
Other (list)
What is the actual primary activity of the visit? Check one
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
13614-NR (Rev. 10-2020)
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. 2014 2015 2016 2017 2018 2019
Have you ever been present in the U.S. PRIOR to 2014 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
2018 2019 2020
List the dates you entered and left the United States during 2020
Date entered United States
Date departed United States
Date entered United States
Date departed United States
Did you file a U.S. income tax return for any year before 2020? Yes No
If “Yes”, give latest year
/ /
Form number filed
During 2020, 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
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? Yes No
Information about academic institution you attended in 2020
Name Telephone number
Name of your academic/specialized program director
Telephone number
During 2020 did you receive
Scholarships or Fellowship Grants Yes No
Wages, Salaries or Tips Yes No
Interest Yes No
Distributions from IRA, Pension or Annuity
Yes No
State or Local Tax Refunds Yes No
Unemployment Compensation Yes No
Dividend income or capital gains or losses Yes No
Any Other Income (gambling, lottery, prizes, awards, self-employment, rents, royalties, virtual currency, etc.) Yes No
Did you have
Casualty Losses in a Declared Disaster
Yes No
Student Loan Interest Paid Yes No
State or Local Income Taxes Yes No
U.S. Charitable Contributions Yes No
Child/Dependent Care Expenses Yes No
IRA Contributions Yes No
Did you or any dependent have health insurance coverage through (The Marketplace)?
No Yes If yes, was any Advanced Premium Tax Credit received? (Provide Form 1095-A)
Yes No
Privacy Act and Paperwork Reduction Act Notice
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.