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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.
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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 nameYour 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 residenceAddress in the United States
Part IGeneral Information
1a
Type of U.S. visa (for example, F, J, M, Q, etc.) and date you entered the United States
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b
Current nonimmigrant status and date of change (see instructions)
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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
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4aEnter the actual number of days you were present in the United States during:
201220112010
b
Enter the number of days in 2012 you claim you can exclude for purposes of the substantial presence test
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Part IITeachers and Trainees
5
For teachers, enter the name, address, and telephone number of the academic institution where you taught in 2012
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6For trainees, enter the name, address, and telephone number of the director of the academic or other specialized program
you participated in during 2012
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7Enter the type of U.S. visa (J or Q) you held during:
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20062007
2008200920102011
. 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) ........................
YesNo
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 IIIStudents
9
Enter the name, address, and telephone number of the academic institution you attended during 2012
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10Enter the name, address, and telephone number of the director of the academic or other specialized program you participated
in during 2012
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11Enter the type of U.S. visa (F, J, M, or Q) you held during:
▶
20062007
2008200920102011
. 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.
12Were you present in the United States as a teacher, trainee, or student for any part of more than 5 calendar
years ..................................
YesNo
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.
13During 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 ..........................