University of Notre Dame International Tax Assistance Program – 2019 (2018 Tax year)Intake Form (adapted from IRS Form 13614-NR)
Updated: 11/29/2018
Name (please print): ______
Email address:______Date of birth: ______
Local Street Address: ______
City, State, Zip Code:______
Foreign Residence Address: ______
______
Country of citizenship: ______
Country that issued your passport: ______
Country of residence (Country where you last lived for at least one year immediately before you came to the United States): ______
Are you married?Yes ____ No ____ If “yes,” is your spouse in the U.S.? ______
Is your spouse a U.S. citizen? ______Spouse’s Name: ______
Are you a resident of: Mexico _____ India _____ South Korea _____ Canada _____
Are you blind?Yes ____ No ____
Dependent information:
First and last name / Date of birth / Relationship(daughter, son, etc.) / Months lived with you in the US / Place of birth / Did you provide more than 50% of support?
Date you first entered the United Stateson either an F or J Visa:______
Visa status when you first entered the U.S.: F-1 ______J-1 ______Other ______
Current Visa status:F-1 ______J-1 ______Other ______
Date of visa status change(if applicable): ______
If Immigration Status is J-1, what is the sub-type?
_____ Student (01) _____ Professor (05)
_____ Short-Term Scholar (02)_____ Research Scholar (12)
Enter the type of U.S. visa you had during each of these years:
2011 ____ 2012 ____ 2013 ____ 2014 ____ 2015 ____ 2016 ____ 2017 ____
What is the actual, primary activity of your visit?
_____ Studying in a degree program (01) _____ Lecturing (04)
_____ Studying in a non-degree program (02)_____ Conducting Research (07)
_____Teaching (03)_____ Here with spouse (12)
Other (please describe) ______
Check the years you were present in the U.S. as a teacher, trainee, or student for any part of the year.
2013 ____ 2014 ____ 2015 ____ 2016 ____ 2017 ____2018 ____
Were you present in the U.S. as a teacher, trainee, or student for any part of more than any five calendar years? Yes ____ No ____
How many days were you present in the U.S. during the following years?
2015 ____ 2016 ____ 2017 ____ 2018 ____
List the dates you entered and left the U.S. during 2018 (please consult your I-94 form online for accurate information):
Entered LeftEntered LeftEntered Left
______
______
Did you file a U.S. Federal Income Tax Return for any previous year?
Yes ____ No ____ If “Yes,” latest year and form number filed ______
If you fileda U.S. tax return last year, did the International Tax Assistance Program prepare them? Yes _____ No _____
During 2018, did you apply to be a lawful, permanent resident of the U.S. (Green Card holder)? Yes ____ No ____
Do you have an application pending to change your status to lawful, permanent resident? Yes ____ No ____
Are you claiming the benefits of a U.S. income tax treaty with a foreign country?
Yes ____ No ____ Don’t know ____Country ______
Were you subject to tax in a foreign country on the income claimed above?
Yes ____ No ____
Your College, School, or other organization within the University of Notre Dame:
Architecture____Business Administration____Law____
Arts & Letters ____Nanovic Institute____Kroc Institute ____
Engineering ____Science____
First Year Undergraduate ____Other______
During 2018, did you receive or pay any of the following:
____Wages, Salaries, or Tips ____Business Expenses
____Scholarships or Fellowship grants____Student Loan Interest
____Interest or Dividend Income____State or Local Income Taxes
____Distribution from an IRA, Pension,
or Annuity____U.S. Charitable Contributions
____Business Income____IRA Contributions
____Unemployment Compensation____Child/Dependent Care Expenses
____Capital Gains or Losses____Any other income
Did you and all of the members of your family have health insurance during 2018?
Yes ______No ______
Did you or any of your family members purchase health insurance through an Affordable Care Act (ACA) Marketplace? Yes _____ No _____ Don’t know _____
State of Indiana Information Request
Did you have income from any state other than Indiana?
Yes ____ No ____If “Yes,” which state(s) ______
Except for temporary absences such as winter break, were you living in Indiana on January 1, 2018? Yes ____ No ____
Did you receive a state tax refund during 2018 associated with tax year 2017?
Yes ____ No ____ Amount ______
Did you rent from a private landlord in Indiana during 2018? (This does not include the University of Notre Dame.) Yes ____ No ____
If “Yes,” number of months rented during 2018 ______
Total rent paid during 2018______
Name and address of landlord ______
______
______
Did you make a charitable donation of money to an Indiana college or university during 2018 (does NOT include tuition)?
Yes ____ No ___
If “Yes,” amount of contribution ______Date of Contribution ______
College or university ______
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 20220
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