Washburn University Nonresident Alien Tax Assessment Form

This form must be completed before you can receive any form of payment from Washburn University. All applicable questions below must be answered. The completed form must be presented with your passport and immigration documents as soon as possible before payment will be made (for Washburn employees, including student employees, at the time of appointment).

PERSONAL/PASSPORT INFORMATION

Last or Family Name:
First:
Middle:
Date of Birth: (mm/dd/yyyy) // E-mail Address:
Social Security # (or Individual Taxpayer ID # if no SS#): --
WIN #:
Country of citizenship:
Country that issued passport:
Passport #: Passport Expiration Date: (mm/dd/yyyy) //
Visa # (red number in lower right corner of stamp in passport):

ADDRESSES
U.S. Local Street Address:
Address Line 1 Address Line 2
City State Zip Code
Foreign (home) Residence Address (should not be P.O. Box)
Address Line 1:
Address Line 2:
Address Line 3:
City City Postal Code
Province/Region Region Postal Code
Country

CURRENT IMMIGRATION STATUS
U.S. Immigrant/Permanent Resident F-1 Student
H-1B Temporary Worker J-2 Dependent
J-1 Exchange Visitor Other:
--IF J-1 Exchange Visitor, what category?
Student Research Scholar Short Term Scholar Alien Physician Other:

PRIMARY ACTIVITY DURING THIS VISIT (Choose only one)
Studying in a degree program Observing Demonstrating special skills
Studying in a non-degree program Consulting Clinical activities
Teaching Conducting research Temporary employment
Lecturing Training Here with spouse
What was the start date of your immigration status for the current activity? //
(In many cases, this is the date you entered the U.S.) month/day/year
What is the projected end date of your primary activity? //
(In many cases, this is the completion date on your immigration document.) month/day/year
If you are a student, at what level do you study?
Undergraduate Masters Law School Other:
Describe the activity that will result in U.S. income (i.e., professor of physics, consulting, lecturer/speaker, food service worker, scholarship, contest prize, etc.)
WU department providing the income? Annual Amount?

TAX EXEMPTIONS INFORMATION
Skip to next section if you are not married
Is your spouse in the U.S.? Yes No Is your spouse employed? Yes No
Do you want to claim an exemption for your spouse if legally allowed to do so? Yes No
Do you have other dependents in the U.S. you would like to claim exemptions for?
Yes No If so, how many?

RESIDENCY VERIFICATION
What country did you live in for a least one year before this visit to the U.S.?
If the country listed above is the same as your country of citizenship, please skip to the next section.
Do you pay taxes as a resident of that country? Yes No
Does your tax residency in that country end prior to this visit to the U.S.?
Yes No If yes, when? //

U.S. IMMIGRATION HISTORY, Part 1
This section is designed to provide information about previous visits to the U.S. for persons who have had a different immigration status than that which they now hold. It is also for persons who have had absences from the U.S. of more than 5 months, even if they returned in the same immigration status they had previously. Do NOT complete this section unless your immigration status has changed or you have been absent from the U.S. for more than 5 months.
 
If the answer to either of the questions below is yes, please complete U.S. Immigration History, Part 2
Have you ever had another immigration status in the United States? Yes No
Have you ever been present in the United States before this visit? Yes No

U.S. IMMIGRATION HISTORY, Part 2
Please list any F, J, M or Q visa immigration activity since January 1, 1985 and all other visa immigration activity only for the past three calendar years
Date of US Entry month/day/year //
Date of US Exit month/day/year //
Visa/Immigration Status
J-1 Subtype
Primary Activity
Have you Taken Any Treaty Benefits? Yes No
Date of US Entry month/day/year //
Date of US Exit month/day/year //
Visa/Immigration Status
J-1 Subtype
Primary Activity
Have you Taken Any Treaty Benefits? Yes No
Date of US Entry month/day/year //
Date of US Exit month/day/year //
Visa/Immigration Status
J-1 Subtype
Primary Activity
Have you Taken Any Treaty Benefits? Yes No
Date of US Entry month/day/year //
Date of US Exit month/day/year //
Visa/Immigration Status
J-1 Subtype
Primary Activity
Have you Taken Any Treaty Benefits? Yes No
Date of US Entry month/day/year //
Date of US Exit month/day/year //
Visa/Immigration Status
J-1 Subtype
Primary Activity
Have you Taken Any Treaty Benefits? Yes No
I hereby certify that all of the above information is true and correct. I understand that if my status changes from that which I have indicated on the form I must submit a new Tax Assessment Form.

Local Phone Number: // Date: //

When you have completed this form, print out the form and take it with applicable documentation to either the Office of International Programs (students), the Academic Affairs office (faculty), Human Resources (other employees) or the Finance Office (all other foreign nationals).
 
If you have questions about this application, please e-mail Chris Leach.
Adapted with permission of University of Missouri

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