Form 8843 - Statement For Exempt Individuals And Individuals With A Medical Condition
Download a blank fillable Form 8843 - Statement For Exempt Individuals And Individuals With A Medical Condition in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 8843 - Statement For Exempt Individuals And Individuals With A Medical Condition with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
48843
Statement for Exempt Individuals and Individuals
OMB No. 1545-0074
With a Medical Condition
2016
Form
For use by alien individuals only.
Information about Form 8843 and its instructions is at
▶
Attachment
102
For the year January 1—December 31, 2016, or other tax year
Sequence No.
Department of the Treasury
beginning
, 2016, and ending
, 20
.
Internal Revenue Service
Your first name and initial
Last name
Your U.S. taxpayer identification number, if any
John L.
Doe
123456789
Fill in your
Address in country of residence
Address in the United States
addresses only if
you are filing this
form by itself and
not with your tax
return
your home country address if NOT filling with tax return
your US address if NOT filling with tax return
Part I
General Information
1a Type of U.S. visa (for example, F, J, M, Q, etc.) and date you entered the United States
▶
example F1 01/02/2016
b Current nonimmigrant status and date of change (see instructions)
▶
Of what country were you a citizen during the tax year?
2
home country / permanent residency before coming to the US
3a What country issued you a passport?
same as #2
b Enter your passport number
123456789
▶
4a Enter the actual number of days you were present in the United States during:
2016
eg. 365
2015
365
2014
365
b Enter the number of days in 2016 you claim you can exclude for purposes of the substantial presence test
▶
Part II
Teachers and Trainees
For teachers, enter the name, address, and telephone number of the academic institution where you taught in 2016
5
▶
6
For trainees, enter the name, address, and telephone number of the director of the academic or other specialized program
you participated in during 2016
▶
7
Enter the type of U.S. visa (J or Q) you held during:
2010
2011
▶
. If the type of visa you held during any
2012
2013
2014
2015
of these years changed, attach a statement showing the new visa type and the date it was acquired.
8
Were you present in the United States as a teacher, trainee, or student for any part of 2 of the 6 prior
Yes
No
calendar years (2010 through 2015)? .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
If you checked the “Yes” box on line 8, you cannot exclude days of presence as a teacher or trainee unless
you meet the Exception explained in the instructions.
Part III
Students
9
Enter the name, address, and telephone number of the academic institution you attended during 2016
▶
eg. Georgia State University, 33 Gilmer Street SE Atlanta, GA, 30302, (404) 413-2000
10
Enter the name, address, and telephone number of the director of the academic or other specialized program you participated
in during 2016
▶
Dr. John Doe, ISSS, Georgia State University, 33 Gilmer St. SE Atlanta, GA 30303, (404) 413-2070
11
Enter the type of U.S. visa (F, J, M, or Q) you held during:
-
-
2010
2011
▶
. If the type of visa you held during any
2012
-
2013
F
2014
F
2015
F
of these years changed, attach a statement showing the new visa type and the date it was acquired.
12
Were you present in the United States as a teacher, trainee, or student for any part of more than 5 calendar
years? .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
Yes
No
If you checked the “Yes” box on line 12, you must provide sufficient facts on an attached statement to
establish that you do not intend to reside permanently in the United States.
13
During 2016, did you apply for, or take other affirmative steps to apply for, lawful permanent resident status
in the United States or have an application pending to change your status to that of a lawful permanent
resident of the United States? .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
Yes
No
If you checked the “Yes” box on line 13, explain
14
▶
-
8843
For Paperwork Reduction Act Notice, see page 4.
Form
(2016)
Cat. No. 17227H
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 8843 - Statement For Exempt Individuals And Individuals With A Medical Condition - 2017
Financial
Form 8843 - Statement For Exempt Individuals And Individuals With A Medical Condition - 2012
Financial
Form 8843 - Statement For Exempt Individuals And Individuals With A Medical Condition - 2013
Financial
Form 8843 - Statement For Exempt Individuals And Individuals With A Medical Condition - 2014
Financial
Form 8843 - Statement For Exempt Individuals And Individuals With A Medical Condition - 2015
Financial
Instructions For Filing Form 8843 - Statement For Exempt Individuals And Individuals With A Medical Condition
Financial
Related Categories
Parent category: Financial