Name:   

Social Security Number/ITIN:   

Date of Birth:   

Citizenship:   

Passport Number:   

(Attach copy of Passport picture page)

Are you married?

Address Overseas:

Phone/Cell Phone:   

Fax:   

e-mail:   

Address in USA (if any):

Name and address of employer(s):

U.S. Visa type and effective dates:

(Attach copy of Visa page from your passport)

Date you first entered the USA:   

Dates you entered and left the USA last year:

Number of days in the USA each year during the prior three years:

Have you filed a U.S. tax return before?

U.S. Social Security exemption? (D/USA 101):

Income earned in USA (Enclose W-2 Form or foreign equivalent and IRS 1099 and K-1 forms showing U.S. source income):

USA living expenses not paid by your employer? (List type and amount):

Additional Comments:

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