ࡱ> ^`]{ bjbjzz *8JJ,D)"(((((!!!!!!!$!#%d!!((!^((!!` `!(6 pF,!!!0)"F!7&.7&4`!7&`!4!!)"7&J j:  NOTE: This is the same information asked for on your tax forms. Fill out this sheet and bring it to the tax workshop. You will copy the information onto the online tax forms. Having this information available beforehand will save you time! Passport Number: _____________________________________________ Current visa/immigration status. Select One F-1 ___ J-1 ___ F-2___ J-2 ___ Other _______ Your original date of entry to the U.S. for the purpose of this visit: mm/dd/yy___________ The end date of this visit (enter your graduation date; its on I-20): mm/dd/yy____________ Have you changed your immigration status since arriving in the U.S. for this visit? Different_______ Same ________ Is this the first time you have been to the U.S.? Yes_______ No ________ How long have you been present in the United States Calendar Immigration Status Estimated total Days Days not present Year Present calendar year 2012 ______ 365 _________ 2011 ______ 365 _________ 2010 ______ 365 _________ 2009 ______ 365 _________ 2008 ______ 365 _________ Country of Citizenship: (If you are a citizen of 2 countries, please select the country under whose documents you entered the U.S. If you are a dual citizen of the U.S. and another country, for U.S. tax purposes you are treated as a citizen of the U.S.) ------------------------------------------------------- Passport Country: Country under whose passport you entered U.S._________________________ Country of Tax Residence: Your country of tax residence is generally the country to which you owe tax on your worldwide income. Typically this is the same as your country of permanent residence; however if you have lived in a country other than your country of permanent residence immediately before coming to the U.S. to study/work, you may have established residence in that country. What income forms/statements did you receive? Please check all that apply. ___ Form W-2 ___ Form 1042S ___ Form 1099-MISC (miscellaneous income) ___Form 1099 INT (Interest) ___ Form 1099-DIV (Dividends) ____ Form 1099-B (Broker/Barter) ___Form 1099-G (State Tax Refund) ____ Form 1099-R What is your marital status? If you were not married at anytime during 2012, mark Single. NOTE: If you are married and your spouse resides in another country, you ARE still considered married. ___________ Single ___________ Married During the tax year 2012 did you make any charitable donations to US organizations (religious, charitable, educational, scientific, or literary? ____________ yes __________ no NOTE: If you answer YES to this you will be required to file form 1040 NR (Long Form) Personal information What is your social security number of Taxpayer Identification number (ITIN) Do not include dashes when typing in SS number ___________________________________ What is your current U.S. Mailing address? Street address ____________________________________________________________ City _________________________________ State _________ Postal Code ___________ What is your permanent foreign mailing address: Street address _______________________________ City ____________________ State/Province _____ Postal Code _______ Country ______ Name of Academic Advisor: WRITE THE FOLLOWING: Rochelle Gorman Phone number of Advisor: WRITE THE FOLLOWING: 413-559-5779 What is your relationship to the U.S.? Have you ever been a U.S. citizen Yes ________No ______ Have you ever been a U.S. permanent resident alien (i.e., greencard holder)? Yes ________ No _______ Did you surrender your U.S. permanent resident status during 2012? Yes________ No _______ During the tax year 2012 did you apply for or take other affirmative steps to apply for lawful permanent resident status in the U.S. or have an application pending to change your status to that of a lawful permanent resident of the U.S.? Yes _______ No _______ Please explain what action you have taken Did you temporarily leave the U.S. during the tax year 2012? During the tax year 2012 did you temporarily leave the U.S. (e.g. for vacation, holiday, summer break)? Yes _______ No_________ Please indicate the departure and entry dates for each of your MOST recent temporary leaves from the U.S. during the tax year 2012. Departure Date #1 Day ________ Month __________ Year _________ Reentry date #1 Day ________ Month __________ Year _________ Departure Date #2 Day ________ Month __________ Year _________ Reentry date #2 Day ________ Month __________ Year _________ Departure Date #3 Day ________ Month __________ Year _________ Reentry date #3 Day ________ Month __________ Year _________ Have you ever filed a U.S. income tax return? 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