FOREIGN NATIONAL (NRA) TAX STATUS FORM

Web Address for Form Instructions: www.siue.edu/humanresources/forms/pdf/NRA_Tax_Status_Form_Instructions.doc

Basic Info
Last Name
First Name
Middle Name
Maiden Name (if applicable)
Date of Birth
Banner ID
University Status	Employee Undergrad Student Grad Student Non-Employee
Personal Info
Personal Exemption Allowed	Marital Status
SIUE Department
Position – 1st
Position – 2nd (if applicable)
Home Telephone #	( ) - Ext
Day Telephone # or Cell #	( ) - Ext
SIUE Email Address	@siue.edu
Other Email Address
Date First Entered USA	Date of Employment
USA Address
Address Line 1
Address Line 2
City
State	Zip	-

Foreign Address
Address Line 1
Address Line 2
Address Line 3
City Postal Code
City
Province/Region
Region Postal Code
Country
Country Info (attach copy of Passport)
Home Country
Passport/Citizenship
Passport Number
Passport Expiration Date
Tax country residence	Also a U.S. Citizen?
Visa/Immigration Current Status Detail – 1 (attach copy of your Visa and I-20/DS2019)
Immigration Status / Visa Type
Primary Purpose
Tax Residence
Visa Number	Use treaty benefits if available?
I-20/DS2019 Start Date
First Day in USA in this Status (date from first I-20/DS2019)	Last Day in USA in this Status

(date from I20/DS2019)
SEVIS ID

Visa/Immigration Previous Status Detail – 2 (attach copy ) or N/A
Immigration Status / Visa Type
Primary Purpose
Tax Residence
Visa Number	Were treaty benefits used?
INS/USCIS Visa Start Date
First Day in USA in this Status	Last Day in USA in this Status
SEVIS ID
Visa/Immigration Previous Status Detail – 3 (attach copy ) or N/A
Immigration Status / Visa Type
Primary Purpose
Tax Residence
Visa Number	Were treaty benefits used?
INS/USCIS Visa Start Date
First Day in USA in this Status	Last Day in USA in this Status
SEVIS ID
CERTIFICATION

I declare under penalties of perjury that the information provided above is true and correct. If I receive an extension of my visa status, or if my visa/immigration status changes, I will notify the Payroll Department at 618/650-2190 and provide updated support.
Signature
Date:

5/7/12 – previous versions obsolete

Joyree Chura

2012-05-14

Southern Illiniois University Edwardsville