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

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

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