THE UNIVERSITY OF MICHIGAN - PAYROLL OFFICE
ALIEN CERTIFICATE AC
If you are not a citizen of the United States, you must complete this Alien Certificate. Return the completed Alien Certificate to:
Payroll Office, G395 Wolverine Tower, 3003 S. State St, Ann Arbor, MI 48109-1279 or via fax (734)647-3983.
PLEASE PRINT
SECTION I – To be completed by all non-residents (even those who do not enter the U.S.)
Name: _________________________________________________________________________ _______________________
Last First Middle Social Security Number
I certify that I am a resident of the country of _______________________________________ _______________________
UMID
SECTION II – Complete this section only if you have entered the United States.
Include your original date of entry, date of Visa change if any, and any time you were gone from the U.S. for 365 days or more.
Report all visits to the U.S. including visits not affiliated with The University of Michigan. If more lines are needed for additional
visits to the U.S. include on a separate piece of paper and attach that information to this form.
I entered the United States on on a(n) I left the U.S. on I was a (check one)
_______________________ ________ __________________ Student Non-Student
Month Day Year Visa Type Month Day Year
_______________________ ________ __________________ Student Non-Student
Month Day Year Visa Type Month Day Year
_______________________ ________ __________________ Student Non-Student
Month Day Year Visa Type Month Day Year
I certify that my type of VISA is: F1 J1 J2
Other (specify) ____________________
If you are a J-1 visa holder check the one box below that applies to visa information on your Form DS-2019 and attach a copy of
your Form DS-2019 to this form.
J1 Teacher J1 Professor J1 Research Scholar J1 Short Term Scholar
J1 Student J1 Government Visitor J1 International Visitor J1 Specialist
J1 Summer Travel or Work J1 Trainee or Intern
If you are Lawful Permanent Resident, Green Card holder check box:
If you are eligible to claim a tax treaty exemption as a teacher/researcher, you must file a Form 8233 with the proper attachment for
your country of residence. If you are eligible to claim a tax treaty exemption as a student, you must file a Form 8233 with the
proper attachment for your country of permanent residence. If you are eligible to claim a tax treaty exemption as fellowship/
scholarship, you must file a Form W8-BEN. All forms are available on the Payroll website at http://payroll.umich.edu/formreq.html.
SECTION III - I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE ALL OF THE INFORMATION I HAVE PROVIDED ABOVE
IS TRUE, CORRECT AND COMPLETE. I UNDERSTAND THAT IF MY STATUS CHANGES FROM THAT WHICH I HAVE
INDICATED ON THIS FORM, I MUST SUBMIT A NEW ALIEN CERTIFICATE TO THE UM PAYROLL OFFICE.
Date: ________________________ Your signature: _________________________________________
Alien Certificate
H1-B
Date of birth
___________________
Month Day Year
07/17