IRS Form 8843 2017 Statement for Exempt Individuals and Individuals With a Medical Condition

IRS Form 8843 is a U.S. Department of the Treasury - Internal Revenue Service - issued form also known as the "Statement For Exempt Individuals And Individuals With A Medical Condition".

Download a PDF version of the latest IRS Form 8843 down below or find it on the U.S. Department of the Treasury - Internal Revenue Service Forms website.

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8843
Statement for Exempt Individuals and Individuals
OMB No. 1545-0074
With a Medical Condition
Form
2017
For use by alien individuals only.
Go to www.irs.gov/Form8843 for the latest information.
Attachment
For the year January 1—December 31, 2017, or other tax year
102
Department of the Treasury
Sequence No.
Internal Revenue Service
beginning
, 2017, and ending
, 20
.
Your first name and initial
Last name
Your U.S. taxpayer identification number, if any
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
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. If your status has changed, also enter date of change and previous status. See instructions.
2
Of what country or countries were you a citizen during the tax year?
3a What country or countries issued you a passport?
b Enter your passport number(s)
4a Enter the actual number of days you were present in the United States during:
2017
2016
2015
b Enter the number of days in 2017 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 2017
For trainees, enter the name, address, and telephone number of the director of the academic or other specialized program
6
you participated in during 2017
7
Enter the type of U.S. visa (J or Q) you held during:
2011
2012
. If the type of visa you held during any
2013
2014
2015
2016
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 (2011 through 2016)? .
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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 2017
10
Enter the name, address, and telephone number of the director of the academic or other specialized program you participated
in during 2017
11
Enter the type of U.S. visa (F, J, M, or Q) you held during:
2011
2012
. If the type of visa you held during any
2013
2014
2015
2016
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? .
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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 2017, 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? .
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Yes
No
14
If you checked the “Yes” box on line 13, explain
8843
For Paperwork Reduction Act Notice, see instructions.
Form
(2017)
Cat. No. 17227H
8843
Statement for Exempt Individuals and Individuals
OMB No. 1545-0074
With a Medical Condition
Form
2017
For use by alien individuals only.
Go to www.irs.gov/Form8843 for the latest information.
Attachment
For the year January 1—December 31, 2017, or other tax year
102
Department of the Treasury
Sequence No.
Internal Revenue Service
beginning
, 2017, and ending
, 20
.
Your first name and initial
Last name
Your U.S. taxpayer identification number, if any
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
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. If your status has changed, also enter date of change and previous status. See instructions.
2
Of what country or countries were you a citizen during the tax year?
3a What country or countries issued you a passport?
b Enter your passport number(s)
4a Enter the actual number of days you were present in the United States during:
2017
2016
2015
b Enter the number of days in 2017 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 2017
For trainees, enter the name, address, and telephone number of the director of the academic or other specialized program
6
you participated in during 2017
7
Enter the type of U.S. visa (J or Q) you held during:
2011
2012
. If the type of visa you held during any
2013
2014
2015
2016
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 (2011 through 2016)? .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
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 2017
10
Enter the name, address, and telephone number of the director of the academic or other specialized program you participated
in during 2017
11
Enter the type of U.S. visa (F, J, M, or Q) you held during:
2011
2012
. If the type of visa you held during any
2013
2014
2015
2016
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? .
.
.
.
.
.
.
.
.
.
.
.
.
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.
.
.
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.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
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 2017, 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? .
.
.
.
.
.
.
.
.
.
.
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Yes
No
14
If you checked the “Yes” box on line 13, explain
8843
For Paperwork Reduction Act Notice, see instructions.
Form
(2017)
Cat. No. 17227H
2
Form 8843 (2017)
Page
Part IV
Professional Athletes
15
Enter the name of the charitable sports event(s) in the United States in which you competed during 2017 and the dates of
competition
16
Enter the name(s) and employer identification number(s) of the charitable organization(s) that benefited from the sports
event(s)
Note: You must attach a statement to verify that all of the net proceeds of the sports event(s) were contributed to the charitable
organization(s) listed on line 16.
Part V
Individuals With a Medical Condition or Medical Problem
17a Describe the medical condition or medical problem that prevented you from leaving the United States
b Enter the date you intended to leave the United States prior to the onset of the medical condition or medical problem described
on line 17a
c Enter the date you actually left the United States
18
Physician’s Statement:
I certify that
Name of taxpayer
was unable to leave the United States on the date shown on line 17b because of the medical condition or medical problem
described on line 17a and there was no indication that his or her condition or problem was preexisting.
Name of physician or other medical official
Physician’s or other medical official’s address and telephone number
Physician’s or other medical official’s signature
Date
Sign here
Under penalties of perjury, I declare that I have examined this form and the accompanying attachments, and, to the best of my knowledge and belief,
they are true, correct, and complete.
only if you
are filing
this form by
itself and
not with
your tax
return
Your signature
Date
8843
Form
(2017)
3
Form 8843 (2017)
Page
General Instructions
Specific Instructions
• 183 days during the period 2017, 2016,
and 2015, counting all the days of
Section references are to the Internal
Part I—General Information
physical presence in 2017 but only 1/3
Revenue Code unless otherwise
the number of days of presence in 2016
If you are attaching Form 8843 to Form
specified.
and only 1/6 the number of days in 2015.
1040NR or Form 1040NR-EZ, you aren’t
Future Developments
Note: To claim the closer connection to
required to complete lines 1a through 4a
a foreign country(ies) exception to the
of Form 8843 if you provide the
For the latest information about
substantial presence test described in
requested information on the
developments related to Form 8843 and
Regulations section 301.7701(b)-2, you
corresponding lines of Form 1040NR or
its instructions, such as legislation
must file Form 8840, Closer Connection
1040NR-EZ. In this case, enter
enacted after they were published, go to
Exception Statement for Aliens.
“Information provided on Form 1040NR”
www.irs.gov/Form8843.
or “Information provided on Form
Days of presence in the United States.
Who Must File
1040NR-EZ” on line 1a of Form 8843.
Generally, you are treated as being
present in the United States on any day
If you are an alien individual (other than a
Line 1b. Enter your current nonimmigrant
that you are physically present in the
foreign government-related individual),
status, such as that shown on your
country at any time during the day.
you must file Form 8843 to explain the
current Immigration Form I-94, Arrival-
However, you don’t count the following
basis of your claim that you can exclude
Departure Record. If your status has
days of presence in the United States for
days of presence in the United States for
changed while in the United States, enter
purposes of the substantial presence
purposes of the substantial presence
the date of change and previous status.
test.
test because you:
Part II—Teachers and
1. Days you regularly commuted to
• Were an exempt individual, or
Trainees
work in the United States from a
• Were unable to leave the United States
residence in Canada or Mexico.
A teacher or trainee is an individual who
because of a medical condition or
is temporarily present in the United States
2. Days you were in the United States
medical problem.
under a “J” or “Q” visa (other than as a
for less than 24 hours when you were
When and Where To File
traveling between two places outside the
student) and who substantially complies
with the requirements of the visa.
If you are filing a 2017 Form 1040NR or
United States.
Form 1040NR-EZ, attach Form 8843 to
If you were a teacher or trainee under
3. Days you were temporarily in the
it. Mail your tax return by the due date
a “J” or “Q” visa, you are considered to
United States as a regular crew member
(including extensions) to the address
of a foreign vessel engaged in
have substantially complied with the visa
shown in your tax return instructions.
requirements if you haven’t engaged in
transportation between the United
activities that are prohibited by U.S.
If you don’t have to file a 2017 tax
States and a foreign country or a
immigration laws that could result in the
return, mail Form 8843 to the
possession of the United States unless
loss of your “J” or “Q” visa status.
Department of the Treasury, Internal
you otherwise engaged in trade or
business on such a day.
Revenue Service Center, Austin, TX
Even if you meet these requirements,
73301-0215 by the due date (including
you can’t exclude days of presence in
4. Days you were unable to leave the
extensions) for filing Form 1040NR or
2017 as a teacher or trainee if you were
United States because of a medical
Form 1040NR-EZ.
exempt as a teacher, trainee, or student
condition or medical problem that arose
for any part of 2 of the 6 prior calendar
while you were in the United States.
Penalty for Not Filing
years. But see the Exception below.
5. Days you were an exempt
Form 8843
If you qualify to exclude days of
individual.
If you don’t file Form 8843 on time, you
presence as a teacher or trainee,
Exempt Individuals
may not exclude the days you were
complete Parts I and II of Form 8843. If
present in the United States as a
For purposes of the substantial presence
you have a “Q” visa, complete Part I and
professional athlete or because of a
test, an exempt individual includes
only lines 6 through 8 of Part II. On line
medical condition or medical problem
anyone in the following categories.
6, enter the name, address, and
that arose while you were in the United
telephone number of the director of the
• A teacher or trainee (defined on this
States. Failure to exclude days of
cultural exchange program in which you
page).
presence in the United States could
participated.
• A student (defined on the next page).
result in your being considered a U.S.
Exception. If you were exempt as a
• A professional athlete temporarily
resident under the substantial presence
teacher, trainee, or student for any part
present in the United States to compete
test.
of 2 of the 6 prior calendar years, you
in a charitable sports event.
You won’t be penalized if you can
can exclude days of presence in 2017 as
The term exempt individual also
show by clear and convincing evidence
a teacher or trainee only if all four of the
includes an individual temporarily
that you took reasonable actions to
following apply.
present in the United States as a foreign
become aware of the filing requirements
1. You were exempt as a teacher,
government-related individual under an
and significant steps to comply with
trainee, or student for any part of 3 (or
“A” or “G” visa, other than individuals
those requirements.
fewer) of the 6 prior calendar years.
holding “A-3” or “G-5” class visas. An
Substantial Presence Test
2. A foreign employer paid all your
individual present under an “A-3” or
compensation during 2017.
“G-5” class visa is not considered a
You are considered a U.S. resident if you
foreign government-related individual
3. You were present in the United
meet the substantial presence test for
and must count all his or her days of
States as a teacher or trainee in any of
2017. You meet this test if you were
presence in the United States for
the 6 prior years.
physically present in the United States
purposes of the substantial presence
for at least:
4. A foreign employer paid all of your
test. For more details, see Pub. 519. If
compensation during each of those prior
• 31 days during 2017, and
you are present under any other “A” or
6 years you were present in the United
“G” class visa, you are not required to
States as a teacher or trainee.
file Form 8843.
For more details, see Pub. 519, U.S.
Tax Guide for Aliens.
4
Form 8843 (2017)
Page
Part IV—Professional
If you meet this exception, you must
• The medical condition existed before
attach information to verify that a foreign
your arrival in the United States and you
Athletes
employer paid all the compensation you
were aware of the condition. It does not
A professional athlete is an individual
received in 2017 and all prior years that
matter whether you needed treatment for
who is temporarily present in the United
you were present in the United States as
the condition when you entered the
States to compete in a charitable sports
a teacher or trainee.
United States.
event. For details on charitable sports
Part III—Students
events, see Pub. 519.
Paperwork Reduction Act Notice. We
A student is an individual who is
If you qualify to exclude days of
ask for the information on this form to
temporarily present in the United States
presence as a professional athlete,
carry out the Internal Revenue laws of
under an “F,” “J,” “M,” or “Q” visa and
complete Parts I and IV of Form 8843.
the United States. Section 7701(b) and
who substantially complies with the
its regulations require that you give us
Part V—Individuals With a
requirements of the visa.
the information. We need it to determine
Medical Condition or
if you can exclude days of presence in
If you were a student under an “F,”
Medical Problem
the United States for purposes of the
“J,” “M,” or “Q” visa, you are considered
substantial presence test.
to have substantially complied with the
For purposes of the substantial presence
visa requirements if you haven’t engaged
You aren’t required to provide the
test, don’t count the days you intended
in activities that are prohibited by U.S.
information requested on a form that is
to leave the United States but couldn’t
immigration laws and could result in the
subject to the Paperwork Reduction Act
do so because of a medical condition or
loss of your visa status.
unless the form displays a valid OMB
medical problem that arose while you
control number. Books or records
Even if you meet these requirements,
were in the United States. Whether you
relating to a form or its instructions must
you can’t exclude days of presence in
intended to leave the United States on a
be retained as long as their contents
2017 as a student if you were exempt as
particular day is determined based on all
may become material in the
a teacher, trainee, or student for any part
the facts and circumstances. For more
administration of any Internal Revenue
of more than 5 calendar years unless you
details, see Pub. 519.
law. Generally, tax returns and return
establish that you don’t intend to reside
If you qualify to exclude days of
information are confidential, as required
permanently in the United States. The
presence because of a medical condition
by section 6103.
facts and circumstances to be
or medical problem, complete Part I and
considered in determining if you have
The average time and expenses
lines 17a through 17c of Part V. Have
established that you don’t intend to
required to complete and file this form
your physician or other medical official
reside permanently in the United States
will vary depending on individual
complete line 18.
include, but aren’t limited to:
circumstances. For the estimated
Note: You cannot exclude any days of
averages, see the instructions for your
1. Whether you have maintained a
presence in the United States under any
income tax return.
closer connection to a foreign country
of the following circumstances.
than to the United States (for details, see
If you have suggestions for making
• You were initially prevented from
Pub. 519), and
this form simpler, we would be happy to
leaving, were then able to leave, but
hear from you. See the instructions for
2. Whether you have taken affirmative
remained in the United States beyond a
your income tax return.
steps to change your status from
reasonable period for making
nonimmigrant to lawful permanent
arrangements to leave.
resident.
• You entered or returned to the United
If you qualify to exclude days of
States for medical treatment. It does not
presence as a student, complete Parts I
matter whether you intended to leave the
and III of Form 8843. If you have a “Q”
United States immediately after the
visa, complete Part I and only lines 10
medical treatment but couldn't do so
through 14 of Part III. On line 10, enter
because of unforeseen complications
the name, address, and telephone
from the medical treatment.
number of the director of the cultural
exchange program in which you
participated.

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