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2012 8843 Form

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2012 8843 Form
2012 8843 Form
Form 8843
Department of the Treasury
Internal Revenue Service
Statement for Exempt Individuals and Individuals
With a Medical Condition
For use by alien individuals only.
Information about Form 8843 and its instructions is at www.irs.gov/form8843.
For the year January 1—December 31, 2012, or other tax year
beginning , 2012, and ending , 20 .
OMB No. 1545-0074
2012
Attachment
Sequence No.
102
Your first name and initial Last name Your U.S. taxpayer identification number, if any
Fill in your
addresses only if
you are filing this
form by itself and
not with your tax
return
Address in country of residence Address in the United States
Part I General Information
1a
Type of U.S. visa (for example, F, J, M, Q, etc.) and date you entered the United States
b
Current nonimmigrant status and date of change (see instructions)
2
Of what country were you a citizen during the tax year
3
a
What country issued you a passport
b
Enter your passport number
4a Enter the actual number of days you were present in the United States during:
2012 2011 2010
b
Enter the number of days in 2012 you claim you can exclude for purposes of the substantial presence test
Part II Teachers and Trainees
5
For teachers, enter the name, address, and telephone number of the academic institution where you taught in 2012
6 For trainees, enter the name, address, and telephone number of the director of the academic or other specialized program
you participated in during 2012
7 Enter the type of U.S. visa (J or Q) you held during:
2006 2007
2008 2009 2010 2011
. If the type of visa you held during any
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
calendar years (2006 through 2011) . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
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 2012
10 Enter the name, address, and telephone number of the director of the academic or other specialized program you participated
in during 2012
11 Enter the type of U.S. visa (F, J, M, or Q) you held during:
2006 2007
2008 2009 2010 2011
. If the type of visa you held during any
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 2012, 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
14
If you checked the “Yes” box on line 13, explain
For Paperwork Reduction Act Notice, see page 4.
Cat. No. 17227H
Form 8843 (2012)
2012 8843 Form
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