Catalog Number 39748B www.irs.gov Form 13614-NR (Rev. 5-2023) 

Form 13614-NR

(May 2023) 

Department of the Treasury - Internal Revenue Service

Nonresident Alien Intake and Interview Sheet 

OMB Number 

 1545-1964

Last or family name First Middle initial

Visa # Passport #

Date of birth: 

(mm/dd/yyyy) / / Telephone # E-mail address

Were you a U.S. citizen or resident alien the entire year? Yes No Were you ever a U.S. citizen? Yes No 

U.S. local street address

City State Zip code

Foreign residence address

Address line 2

Foreign country Province/County Postal code

Country of citizenship Country that issued passport

Are you married? Yes No If “YES”, is your spouse in the U.S.? Yes No 

If "YES", is it recognized by the state where you will be filing? Yes No 

Are you a U.S. National 

Yes No 

Resident of 

Canada 

Yes No 

Resident of 

Mexico 

Yes No 

Resident of 

South Korea 

Yes No 

Resident of 

India 

Yes No 

Dependent Information 

First name 

Last or 

family name 

Date of birth 

(mm/dd/yyyy) 

Relationship 

to you (son, 

daughter, 

 none, etc.) 

Number of 

months lived 

with you in 

the 

U.S. in 2023

U.S. citizen, 

U.S. resident alien, 

U.S. national, 

or a resident of 

Canada, Mexico, or 

South Korea 

Did 

person file 

joint return? 

Did person 

provide 

more than 

50% of their 

own 

support? 

Did you 

provide 

more than 

50% of their 

support? 

Did the 

person 

have Gross 

Income of 

$4,700 or 

more? 

What is the date you FIRST entered the United States? / / 

Entry Immigration Status - Check one

U.S. Immigrant/Permanent resident F-1 Student F-2 Spouse or child of student 

H-1 Temporary employee *J-1 Exchange visitor J-2 Spouse or child of exchange visitor 

Other (list) 

Current Immigration Status - Check one

U.S. Immigrant/Permanent resident F-1 Student F-2 Spouse or child of student 

H-1 Temporary employee *J-1 Exchange visitor J-2 Spouse or child of exchange visitor 

Other (list) 

Have you ever changed your visa type or U.S. immigration status? Yes No 

If “Yes”, indicate the date and nature of the change. / / 

Enter the type of U.S. visa you held during these years

2017 2018 2019 2020 2021 2022

* If Immigration status is J-1, what is the subtype? Check one 

01 Student 

02 Short term scholar 

05 Professor 12 Research scholar 

Other (list) 

What is the actual primary activity of the visit? Check one

01 Studying in a degree program 

02 Studying in a non-degree program 

03 Teaching 

04 Lecturing 

05 Observing 

06 Consulting 

07 Conducting research 

08 Training 

09 Demonstrating special skills 

10 Clinical activities 

11 Temporary employment 

12 Here with spouse 
Catalog Number 39748B www.irs.gov Form 13614-NR (Rev. 5-2023) 

Check the years you were present in the United States as a teacher, trainee, student or as an accompanying spouse or 

dependent of a person in such status for any part of the year. 2017 2018 2019 2020 2021 2022

Have you ever been present in the U.S. PRIOR to 2017 on a teacher, trainee, student visa, or as their accompanying spouse or 

dependent? Yes No If so, what years and visa type

How many days (including vacations, nonworkdays and partial days) were you present in the U.S. during

2021 2022 2023

List the dates you entered and left the United States during 2023

Date entered United States 

mm/dd/yyyy 

Date departed United States 

mm/dd/yyyy 

Date entered United States 

mm/dd/yyyy 

Date departed United States 

mm/dd/yyyy 

Did you file a U.S. income tax return for any year before 2023? Yes No 

If “Yes”, give latest year / / Form number filed 

During 2023, did you apply to be a green card holder (lawful permanent resident) of the United States? Yes No 

Do you have an application pending to change your status to lawful permanent resident? Yes No 

1. Are you claiming the benefits of a U.S. income tax treaty with a foreign country? Yes No 

If “Yes”, enter the appropriate information in the columns below

(a) Country (b) Tax treaty article (c) Number of months 

claimed in prior tax years 

(d) Amount of exempt 

income in current tax year 

2. Were you subject to tax in a foreign country on any of the income shown in 1(d) above? Yes No 

Information about academic institution you attended in 2023

Name Telephone number

Address

Name of your academic/specialized program director

Address

Telephone number

During 2023 did you receive

Scholarships or fellowship grants Yes No 

Wages, salaries or tips Yes No 

Interest Yes No 

Distributions from IRA, pension or annuity Yes No 

State or local tax refunds Yes No 

Unemployment compensation Yes No 

Dividend income or capital gains or losses Yes No 

Any other income (gambling, lottery, prizes, awards, self-employment, rents, royalties, virtual currency, etc.) Yes No

Did you have

Casualty losses in a declared disaster 

area

Yes No

Student loan interest paid Yes No

State or local income taxes Yes No

U.S. Charitable contributions Yes No 

Child/Dependent care expenses Yes No 

IRA contributions Yes No 

Did you or any dependent have health insurance coverage through HealthCare.gov (The Marketplace)?

If yes, was any Advanced Premium Tax Credit received? (Provide Form 1095-A) Yes No 

Yes No 

Privacy Act and Paperwork Reduction Act Notice

The Privacy Act of 1974 requires that when we ask for information we tell you our legal right to ask for the information, why we are asking for it, and how it will be used. We 

must also tell you what could happen if we do not receive it, and whether your response is voluntary, required to obtain a benefit, or mandatory. 

Our legal right to ask for information is 5 U.S.C. 301. We are asking for this information to assist us in contacting you relative to your interest and/or participation in the IRS 

volunteer income tax preparation and outreach programs. The information you provide may be furnished to others who coordinate activities and staffing at volunteer return 

preparation sites or outreach activities. The information may also be used to establish effective controls, send correspondence and recognize volunteers. Your response is 

voluntary. However, if you do not provide the requested information, the IRS may not be able to use your assistance in these programs. 

The Paperwork Reduction Act requires that the IRS display an OMB control number on all public information requests. The OMB Control Number for this study is 1545-2075. 

Also, if you have any comments regarding the time estimates associated with this study or suggestion on making this process simpler, please write to the Internal Revenue 

Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, Washington, DC 20224.