Beruflich Dokumente
Kultur Dokumente
First
Date of Birth
Middle
NC State (Student/Staff) ID #
E mail Address:
What was the arrival date of your FIRST visit to the US? (If you have been in the US for
any reason, including tourism, prior to your arrival at NC State please complete
section 1 on page 2 of this form.)
Address in United States
Street Address 1
Street Address 1
Street Address 2
Street Address 2
City
City
State
Zip Code
Province/Region
Postal Code
Country of citizenship
Country
Foreign Taxpayer ID
Passport expiration date
Passport #
Are you a citizen of any country other than your country of birth?
(i.e. Do you have a passport from another country or are your
parents citizens of another country? )
Visa Type
Yes
No
Yes
No
Yes
No
No
I hereby certify that all of the above information is true and correct. I understand that if any of the information changes I must contact the
International tax office immediately.
Signature
Date
Please send a PDF version of your completed form to: foreignnationaltax@ncsu.edu prior to your tax assessment.
Visa Type
Immigration Status
Date of Exit
Subtype
(If on a J-1 Visa)
Primary Activity
of Visa
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Section 2 - If you have lived in another country in the last five years, prior to coming to the US, your country of tax residence may be
different from your foreign residency address.
Have you lived (worked/attended school) in another country other than the US or your home country in the last five years?
Yes
No
Name of Country
Start Date
End Date
I consent to allow International Employment & Taxation (IET) to access my electronic I-94 record and/or travel history using the U.S.
Customs and Border Protection's online I-94 retrieval system at www.cbp.gov/i94. Initial: