ࡱ> 7 'bjbjUU "7|7|lzzzzzzzTE-6(^^^^^td6,,,,,,,$=. ]0B,z^^B, zz^^, z^z^, , . 8&zz8&^* `A^\<\ 8&8&-0E-8&0 08& zzzzLOUISIANA STATE UNIVERSITY HEALTH SCIENCE SYSTEM Alien Tax Information Request All non-U.S. citizens who receive compensation from Louisiana State University Health Science Center must complete this form. The information you provide is used to determine your residency status for the purposes of U.S. tax withholding. Please print. 1. PERSONAL INFORMATIONLast NameFirst NameMiddleU.S. Social Security Number FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Street Address (In home Country) FORMTEXT      Postal CodeProvince/RegionCityCountry FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      2. STUDENT INFORMATIONName of Academic DepartmentAre you a student?  FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf you have attended or currently attending another U.S. educational institution, provide:Did you receive tax treatyName of educational institution: FORMTEXT      benefits at another U.S. educational institutionPeriod of attendance: From FORMTEXT      to FORMTEXT      during the current year?Degree Granted (if any): FORMTEXT       FORMCHECKBOX  Yes  FORMCHECKBOX  No3. IMMIGRATION & ALIEN TAX INFORMATION (Permanent residents with Green Cards may skip section 3.g, but must provide copy of documentation)a. Date of first U.S. entry  FORMTEXT      b(1). Visa type upon first U.S. entry  FORMTEXT      b(2). If you arrived on spouse/dependent visa, what was the visa type of the primary visa holder (ex. visa type/student or non student)?  FORMTEXT      c. Current Visa type (check appropriate box):d. Country of Birth FORMCHECKBOX  F-1 Student  FORMCHECKBOX  F-1 Student (on practical training)  FORMCHECKBOX  F-2 Spouse/Dependent of F-1  FORMCHECKBOX  H-1 Distinguished Worker FORMTEXT       FORMCHECKBOX  J-1 Student FORMCHECKBOX  J-1 Student (on academic training) FORMCHECKBOX  J-2 Spouse/Dep. of J-1 Student FORMCHECKBOX  TN NAFTA Free Trade FORMCHECKBOX  Other J-1 Visitor (_one) FORMCHECKBOX  Other INS classification (list status):e. Country of Citizenship FORMCHECKBOX  Short-term scholar  FORMTEXT       FORMTEXT       FORMCHECKBOX  Professor FORMCHECKBOX  Research Scholar FORMCHECKBOX  U. S. Permanent Resident (must provide documentation;f. Country of Residence (for tax purposes) FORMCHECKBOX  Other e.g., copy of green card, etc.) FORMTEXT      g. Furnish the requested information to detail the number of days you were physically present in the United States during the calendar years listed below. Note: The term  calendar year refers to the period January 1 to December 31.Calendar Year (e.g. 19 )Number of days present in U.S. during the yearDate of EntryDate of ExitVisaJ-1 Sub type (if applicable)Did you receive tax treaty benefits?Current Calendar year FORMTEXT  DATE \@ "yyyy" 20032003 FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMCHECKBOX  Yes  FORMCHECKBOX  NoLast Calendar year FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMCHECKBOX  Yes  FORMCHECKBOX  NoTwo years ago FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMCHECKBOX  Yes  FORMCHECKBOX  NoThree years ago FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMCHECKBOX  Yes  FORMCHECKBOX  NoFour years ago FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMCHECKBOX  Yes  FORMCHECKBOX  NoFive years ago FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMCHECKBOX  Yes  FORMCHECKBOX  NoSix years ago FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMCHECKBOX  Yes  FORMCHECKBOX  NoRESIDENCE FOR TAX PURPOSES Under Internal Revenue Service definitions, For tax purposes I am considered a  FORMCHECKBOX  RESIDENT ALIEN  FORMCHECKBOX  NONRESIDENT ALIEN 4. CERTIFICATION OF INFORMATIONI certify to the best of my knowledge, all of the information I have provided above is true, correct and complete. Also, I understand it is my responsibility to keep my employment authorization documents including passport, IAP-66, I-20, I-688B, or other INS employment authorization current (un expired) at all times. 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. / R         & U c p u  3 G [  W X f z &:L`t 3G[STbv>?st~@ x[  `@``` ` ```$@```0@```"`H@UnknownG: Times New Roman5Symbol3& : ArialA& Arial Narrow"qh#x&3xf2xf$ʗ,!@r0d2Q0LOUISIANA STATE UNIVERSITY HEALTH SCIENCE SYSTEMgtrangtranOh+'0  0< X d p |1LOUISIANA STATE UNIVERSITY HEALTH SCIENCE SYSTEMAOUIgtranANtratraNormalNgtranN7raMicrosoft Word 9.0V@@82\@֒Z@.O<\՜.+,0 hp  LSUHSC$ 1LOUISIANA STATE UNIVERSITY HEALTH SCIENCE SYSTEM Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXY[\]^_`abcdefghijklmnoprstuvwxyz{|}~Root Entry FNa\<\Data Z-1Tableq0WordDocument"SummaryInformation(DocumentSummaryInformation8CompObjjObjectPoolNa\<\Na\<\  FMicrosoft Word Document MSWordDocWord.Document.89q