Tax Assistance Program
University of Notre Dame International Tax Assistance Program – 2021 (2020 Tax year) Intake Form (adapted from IRS Form 13614-NR)Updated: 02/04/2021Name (please print): ___________________________________________Email address: ____________________________ Date of birth: ________________Local Street Address: ____________________________________________________City, State, Zip Code: ____________________________________________________Phone number _____________________Foreign Residence Address: ___________________________________________________________________________________________________________________Country of citizenship (Please list all): ______________________________ Country that issued your passport (Please list all): _____________________________Country of Residence (Country where you last resided for at least one year immediately before you came to the United States): _________________________________ Are you married?Yes ____ No ____ If “yes,” is your spouse in the U.S.? _________ Is your spouse a U.S. citizen? _______ Spouse’s Name: ________________________Are you a resident of: Mexico _____ India _____ South Korea _____ Canada _____Dependent information:First and last nameDate of birthRelationship(daughter, son, etc.)Months lived with you in the USPlace of birthDid you provide more than 50% of supportDate you first entered the United States on either an F or J Visa: _______________Visa status when you first entered the U.S.: F-1 _______ J-1 _______ Other _______ Current Visa status:F-1 _______ J-1 _______ Other _______Date of change (if applicable): _______________If Immigration Status is J-1, what is the sub-type?_____ Student (01) _____ Professor or Teacher (05)_____ Short-Term Scholar (02)_____ Research Scholar (12) Enter the type of U.S. visa you had during each of these years:2015 ____2016 ____2017 ____2018 ____2019 ____2020 ____ What is the actual, primary activity of your visit?_____ Studying in a degree program (01) _____ Lecturing (04)_____ Studying in a non-degree program (02) _____ Conducting Research (07)_____ Teaching (03)_____ Here with spouse (12)Other ________________________________Students only: Were you present in the U.S. as a teacher, trainee, or student for any part of more than any five calendar years? Yes ____ No ____ J-1 Research Scholars only: Were you present in the U.S. as a teacher, trainee, or student for any part of 2 of the 6 prior calendar years? (2013-2018) Yes ____ No ____ How many days were you present in the U.S. during the following years?Note: We are looking for exact numbers here, NOT ESTIMATES. If you need help, Google “Date Duration Calculator” 2018 ____ 2019 ____ 2020 ____ List the dates you entered and left the U.S. during 2020:Entered LeftEntered LeftEntered Left____________________________________________________________________________________Did you file a U.S. Federal Income Tax Return for any previous year?Yes ____ No ____ If “Yes,” latest year and form number filed _________________If you did file U.S. tax returns last year, did we prepare them Yes _____ No _____During 2020, did you apply to be a lawful, permanent resident of the U.S. (Green Card holder)? Yes ____ No ____Do you have an application pending to change your status to lawful, permanent resident? Yes ____ No ____Are you claiming the benefits of a U.S. income tax treaty with a foreign country?Yes ____ No ____ Don’t know ____Country ___________________Were you subject to tax in a foreign country on the income claimed above?Yes ____ No ____Your College, School, or other organization within the University of Notre Dame:Architecture ____Business Administration____ Law ____Arts & Letters ____Keough, Kroc, or Nanovic____Engineering ____Science____First Year Undergraduate ____Other____During 2020, did you receive or pay any of the following:____Wages ____Casualty or Theft Losses____Scholarships or Fellowship grants____Student Loan Interest____Interest or Dividend Income____State or Local Income Taxes____Self-employment Income____U.S. Charitable Contributions____Business Expenses____Investment Income____Child/Dependent Care Expenses____Any other income Did you or any of your family members purchase health insurance through an Affordable Care Act (ACA) Marketplace? Yes _____ No _____ Don’t know _____Note: Most Notre Dame Students and employees have health insurance through the University.State of Indiana Information RequestDid you have income from any state other than Indiana? Yes ____ No ____If “Yes,” which state(s) ______________________________Except for temporary absences such as winter break, were you living in Indiana on January 1, 2020? Yes ____ No ____Did you receive a state tax refund during 2020 associated with a previous tax year.Yes ____ No ____ Amount ________Did you rent from a private landlord in Indiana during 2020? (This does not include the University of Notre Dame.) Yes ____ No ____If “Yes,” number of mos. rented during 2020 ______ Total rent paid during 2020 ______Name and address of landlord ________________________________________________________________________Did you donate money to an Indiana college or university during 2020? (Paying tuition doesn’t count) Yes ____ No ___ ................
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