ࡱ> tvs'` Xbjbj .fffffff `H`H`H`HHXe KRRRHT#UWAYddddddd$fhindf\#U#U\\dffRHTYe^^^\ fRfHTd^\d^^ff^RHK ʻ`H\"^6^|oe0e^si\si^sif^ZZ^_[t[ZZZdd]ZZZe\\\\XXX\-XXX\-z4"ffffff NON RESIDENT TAX STATUS FORM Web Address for Form Instructions: www.siue.edu/humanresources/forms/pdf/NRA_Tax_Status_Form_Instructions.doc Basic InfoLast Name FORMTEXT      First Name FORMTEXT      Middle Name FORMTEXT      Maiden Name (if applicable) FORMTEXT      Social Security Number (attach copy) FORMTEXT    - FORMTEXT   - FORMTEXT     Date of Birth  FORMTEXT      Banner ID FORMTEXT      University Status FORMCHECKBOX  Employee  FORMCHECKBOX  Undergrad Student  FORMCHECKBOX  Grad Student  FORMCHECKBOX  Non-EmployeePersonal InfoPersonal Exemption Allowed CONTROL Forms.OptionButton.1 \s  CONTROL Forms.OptionButton.1 \s Marital Status CONTROL Forms.OptionButton.1 \s  CONTROL Forms.OptionButton.1 \s SIUE Department FORMTEXT      Position  1st FORMTEXT      Position  2nd (if applicable) FORMTEXT      Home Telephone #( FORMTEXT    )  FORMTEXT    - FORMTEXT      Ext  FORMTEXT      Day Telephone # or Cell #( FORMTEXT    )  FORMTEXT    - FORMTEXT      Ext  FORMTEXT      SIUE Email Address FORMTEXT       @siue.eduOther Email Address FORMTEXT      Date First Entered USA FORMTEXT      Date of Employment  FORMTEXT      USA AddressAddress Line 1 FORMTEXT      Address Line 2 FORMTEXT      City FORMTEXT      State FORMTEXT   Zip FORMTEXT      - FORMTEXT      CONTROL Forms.OptionButton.1 \s  Foreign AddressAddress Line 1 FORMTEXT      Address Line 2 FORMTEXT      Address Line 3 FORMTEXT      City Postal Code FORMTEXT      City FORMTEXT      Province/Region FORMTEXT      Region Postal Code FORMTEXT      Country FORMTEXT       CONTROL Forms.OptionButton.1 \s Country Info (attach copy of Passport)Home Country FORMTEXT      Passport/Citizenship FORMTEXT      Passport Number FORMTEXT      Passport Expiration Date FORMTEXT      Tax country residence FORMTEXT      Also a U.S. Citizen?  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CONTROL Forms.OptionButton.1 \s  CONTROL Forms.OptionButton.1 \s INS/USCIS Visa Start Date FORMTEXT      First Day in USA in this Status FORMTEXT      Last Day in USA in this Status  FORMTEXT      SEVIS ID FORMTEXT      Visa/Immigration Previous Status Detail  3 (attach copy ) or N/AImmigration Status / Visa Type CONTROL Forms.CheckBox.1 \s  CONTROL Forms.CheckBox.1 \s  CONTROL Forms.CheckBox.1 \s  CONTROL Forms.CheckBox.1 \s  CONTROL Forms.CheckBox.1 \s  FORMTEXT      Primary Purpose FORMTEXT      Tax Residence FORMTEXT      Visa Number FORMTEXT      Were treaty benefits used? CONTROL Forms.OptionButton.1 \s  CONTROL Forms.OptionButton.1 \s INS/USCIS Visa Start Date FORMTEXT      First Day in USA in this Status FORMTEXT      Last Day in USA in this Status  FORMTEXT      SEVIS ID FORMTEXT      CERTIFICATION I declare under penalties of perjury that the information provided above is true and correct. 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