Citizenship Status Form - University Of Maryland
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3CITIZENSHIP STATUS FORM – UNIVERSITY OF MARYLAND
Page 1
The following information is furnished for the purpose of determining my U.S. federal income tax withholding status for
payments made to me by the University of Maryland for calendar year____2013________.
● All applicable questions below must be answered or all forms will be returned.
● All copies of the appropriate immigration documents listed on “tip sheets” must be attached or all forms will be returned.
● This form must be completed and returned with all required documents to Payroll Services before any check should be issued.
Have you ever applied for a Social Security Number (SSN) or Individual Taxpayers Identification Number (ITIN)? (ITINs can not
be used for employment)
□ Yes, my number is: ________________________________________________________ use student ID (SID) if no SSN yet.
□ Yes, but I have not received the number yet.
A completed Affidavit of Compliance is REQUIRED if you have no SSN.
□ No, but I will apply immediately for a SSN (or ITIN if Fellow only).
Information concerning application by a foreign worker for a SSN is available at
Name (PRINT CLEARLY) ____________________________________________________________________________________
LAST NAME/FAMILY NAME
FIRST
MIDDLE
U.S. Visa Type or Immigration Status ________________________ I-9 expiration date (N.A. for fellows) ___________________
Country of residence (prior to living in the U.S.)_________________________Citizen of ________________________________
Department
U.I.D __________
_______________________________________
______________
*USCIS=U.S Citizenship and Immigration Services *IF YOU ANSWER “YES” HERE, NO PAGE 2 OR 3 IS NEEDED!
1.
Current USCIS classification and “GREEN CARD TEST”
: Please check one:
a. Permanent Resident (PR): Are you a lawful U.S. immigrant who has an Alien Registration Card (“Green Card”) or an “I-551” stamp in
□
□
your Passport or a USCIS* letter stating approval of your application?
YES*
NO
IF YOU ANSWERED “YES” TO QUESTION (a), you are a Resident Alien for Tax Purposes. You do not need to answer other questions.
Please attach copies of requested documents and sign and date this form on the line below. Pages 2 and 3 are not required for you.
Signature of Permanent Resident^
Date^
print
Payroll representative
name here (and contact number):
2.
IF SECTION 1 DOES NOT APPLY TO YOU, PLEASE CHECK A VISA/IMMIGRATION STATUS BELOW
Permanent Resident Applicant (PP): Have you applied for Permanent Resident status and have a receipt from the USCIS* for
□
□
NO
adjustment of status to PR or have a current Employment Authorization Card (EAC) with Category (c) (9)?
YES
□
□
Are you currently present in the U.S. under Asylum Status (AS)?
YES
NO
□
□
Are you currently in the U.S. under Refugee Status (RF)?
YES
NO
□
□
Are you currently in the U.S. under Temporary Protected Status (TP)?
YES
NO
□
□ F-1 Student
H-1 Temporary Worker in a Specialty Occupation
□ J-1 Student
□ F-1 Student (Optional Practical Training)
□
student
J-2 Spouse/Dependent of J-1 Visitor (
)
□
□
non-student
Other J-1 Visitor (DS-2019, Section 4) ____________________
J-2 Spouse/dependent of J-1 Visitor (
)
Other USCIS classification: ………………………………………………………………
3.
What is the actual date you entered the U.S. for your current primary purpose? ___________________________________
(or what is the start date if you changed immigration status without leaving the US?)
What is the start date of your immigration status for this primary activity? (per most current USCIS documents)
__________
What is the projected end date of your current immigration status? (per most current USCIS documents)
__________
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