Fillable Nonresident Alien Intake and Interview Sheet 2018 Form 13614-NR

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Nonresident Alien Intake and Interview Sheet 2018 Form 13614-NR

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The Internal Revenue Service (IRS) is a government agency responsible for collecting taxes and administering the federal statutory tax laws of the United States. The IRS provide tax assistance to taxpayers and pursue and resolve fraudulent tax filings.

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Form 13614-NR (Rev. 10-2018)
Catalog Number 39748B www.irs.gov Department of the Treasury — Internal Revenue Service
Form 13614-NR
(October 2018)
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
2018
U.S. citizen,
U.S. resident
alien,
U.S. national,
or a resident of
Canada, Mexico,
or South Korea
Did
person file
joint
return?
Did person
provide
more than
50% of
their own
support?
Did you
provide
more than
50% of
their
support?
Did the
person
have
Gross
Income of
$4,150 or
more?
What is the date you FIRST entered the United States?
/ /
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:
2012 2013 2014 2015 2016
2017
* 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
Form 13614-NR (Rev. 10-2018)
Catalog Number 39748B www.irs.gov Department of the Treasury — Internal Revenue Service
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. 2012 2013 2014 2015 2016 2017
Have you ever been present in the U.S. PRIOR to 2012 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:
2016 2017 2018
List the dates you entered and left the United States during 2018:
Date entered United States
mm/dd/yyyy
Date departed United States
mm/dd/yyyy
Date entered United States
mm/dd/yyyy
Date departed United States
mm/dd/yyyy
Did you file a U.S. income tax return for any year before 2018? Yes No
If “Yes”, give latest year
/ /
Form number filed
During 2018, 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 2018
Name: Telephone number:
Address:
Name of your academic/specialized program director:
Address:
Telephone number:
During 2018 did you receive:
Scholarships or Fellowship Grants Yes No
Wages, Salaries or Tips Yes No
Interest or Dividend Income Yes No
Distributions from IRA, Pension or Annuity
Yes No
State or Local Tax Refunds Yes No
Unemployment Compensation Yes No
Capital gains or losses Yes No
Any Other Income (gambling, lottery, prizes, awards, self-employment, rents, royalties, etc.) Yes No
Did you have:
Casualty Losses in a Declared Disaster
Area
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 HealthCare.gov (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.
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Nonresident Alien Intake and Interview Sheet 2018 Form 13614-NR

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Completed 23 May 2019

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