ࡱ> qtp Sbjbj++ IIS     <Z(YYY$~!0$A }eY}}A  WV}  }:c,@3ߤ l0 $Q$$ dYhJ <G6YYYAAYYY}}}}$YYYYYYYYY :  Non - Resident Alien Application Form Complete this form only if you are a Non- Resident alien for tax purposes, and want to exercise your tax Treaty Benefits. This form will be used to determine your tax status for wages paid by the University of Toledo. BASIC INFORMATION: Last Name: First Name: Middle: Social Security Number ______________________ University ID#________________ Date of Birth: USA ADDRESS Street : Apt _________ Toledo, Ohio Zip Code:_____________ Home Phone: Day Phone: E-Mail: FOREIGN ADDRESS (Enter your home or permanent address abroad.) Address line 1____________________________________________ Address line 2__________________________________ City Postal Code ___________________ City _____________________________ Providence / Region _____________________ Regional Postal Code_________________ Country_____________________ COUNTRY INFORMATION What country issued your passport? _________________ Passport Number ________________ Expiration Date_________ Enter the Country for which you are a TAX resident ______________________________ YEAR DATA Estimated annual income from employment at The University of Toledo this calendar year. (Jan 1 - Dec 31) ________________ What are you doing at the University? (IE: Professor, Researcher, Teaching Assistant) ______________________________ PERSONAL FACTS (Check only if applicable.) [ ] I have taken step to become a lawful permanent resident of the U.S. (Attached Green Card or Application) [ ] I am married to a U.S. citizen [ ] I will not be a Tax Resident in my Tax Resident Country at year end. Date tax resident ends_____________ [ ] I am a Dual Resident Taxpayer. List countries________________________________________________ [ ] I do not wish to claim Treaty Exemptions from taxes even though I may qualify. [ ] I have made an election to be taxed as a U.S. resident (Attach Form 1078) Page 2 TYPE OF STUDENT YOU ARE: (check one) [ ] Undergraduate [ ] Graduate Student [ ] Post Graduate [ ] Medical Student Check one: [ ] I am engaged in FULL-TIME study, training, teaching or research. [ ] I am engaged in PART-TIME study, training, teaching or research. Visa Detail Fill in the Visa and Immigration status for each of the last 7 years. Visa TypeVisa NumberPRIMARY reason for entering the U.S. (use code below)Date Arrived in U.S.Left U.S. (or expected departure date)J1 SubtypeCurrent Visa:Prior Visa: Prior Visa:Prior Visa:  Primary Activity Codes: 01 Studying Degree Program 08 Acquire Training 15 Supporting an artist / athlete 02 Studying Non Degree Program 09 Demonstrating Special Skills 16 Tourist 03 Teaching 10 Clinical Activities 17 Business Activities 04 Lecturing 11 Temporary Employment 18 Board of Director Activities 05 Observing 12 Here with Spouse or Relative 19 Practical Training / J-1 F-1 06 Consulting 13 Performing as an artist 20 Educational/ Professional Activities 07 Conducting Research 14 Performing as an Athlete 21 Summer Travel Work J-1 Subtypes 01 Student 06 Specialist 11 Trainee Medical 02 Short Term Scholar 07 Alien Physician 12 Research Scholar 03 Trainee- Non-Medical 08 Other - International Visitor 13 Summer Travel/ Work 04 Teacher 09 Other - Alien of the 99 Not Applicable 05 Professor 10 Other - Camp Counselor ATTACHMENTS CHECKLIST: Before this form can be processed, you must attach copies of the following: Passport (Page 1 only showing your identification and passport number) Visa (Attach copies of your U.S. Visa plus pages clearly showing entry and exit dates) Form I-94 showing current Immigration Status and duration of stay. Copy front and back. Form I-20-ID Certification of Eligibility of Non-immigration (F-1) Student or IAP66 Certification of Eligibility for Exchange visitor (J-1) Status. Remember to bring your visa with you when submitting this form in case there are any questions. Page 3 AUTHORIZATION Under penalties of perjury, I certify that the above information is true, complete, and correct. Sign___________________________________________ Date__________________ Before submitting this form, PLEASE REVIEW: Did you complete each item and fill in all the blanks? Incomplete forms cannot be processed. Did you attach the required documents? Do you have your visa with you when submitting this form to payroll? (Main Campus University Hall 2300) Please send completed application form and required documents to: Email:  HYPERLINK "mailto:payroll@utoledo.edu" payroll@utoledo.edu or Mail: The University of Toledo Payroll Department 2801 W Bancroft St MS 975 Toledo, OH 43606 If you have any questions, please contact me at the following: Email:  HYPERLINK "mailto:payroll@utoledo.edu" payroll@utoledo.edu Phone: (419) 530-8780 Fax: (419) 530-8787 Process: 1) Fill out and return Non-Resident Alien Application Form; 2) Tax Treaty Status and Tax Benefit information is determined; 3) Applicant is informed of Tax Benefits, and Tax Forms are generated and sent to applicant for signatures and dates. 4) Once signed and dated forms have been returned to the Payroll Department, the tax Treaty benefit is entered into the payroll system. 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