Form 8843

Department of the Treasury

Internal Revenue Service

Statement for Exempt Individuals and Individuals

With a Medical Condition

For the year January 1—December 31, 2009, or other tax year

beginning , 2009, and ending , 20 .

OMB No. 1545-0074

Your first name and initial

Address in country of residence

Your U.S. taxpayer identification number, if any

General Information

1a

2

3a

13

5

6

Type of U.S. visa (for example, F, J, M, Q, etc.) and date you entered the United States 

Of what country were you a citizen during the tax year?

What country issued you a passport?

Enter your passport number 

During 2009, 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?

7

8

9

10

11

12

For trainees, enter the name, address, and telephone number of the director of the academic or other specialized program

you participated in during 2009 

Enter the type of U.S. visa (J or Q) you held during: 

Were you present in the United States as a teacher, trainee, or student for any part of 2 of the 6 prior

calendar years (2003 through 2008)?

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 on page 3.

For teachers, enter the name, address, and telephone number of the academic institution where you taught in 2009 

Yes No

Cat. No. 17227H Form 8843 (2009)

Part III

Part I

Part II Teachers and Trainees

Yes No

Students

Enter the name, address, and telephone number of the director of the academic or other specialized program you participated

in during 2009 

Were you present in the United States as a teacher, trainee, or student for any part of more than 5 calendar

years?

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.

Enter the name, address, and telephone number of the academic institution you attended during 2009 

Yes No

14 If you checked the “Yes” box on line 13, explain 

For use by alien individuals only.

Attachment

Sequence No. 102

2005 2006 2007 2008

2003 2004

For Paperwork Reduction Act Notice, see page 4.

Last name

Address in the United States Fill in your

addresses only if

you are filing this

form by itself and

not with your tax

return

b Current nonimmigrant status and date of change (see instructions) 

b

4a

b

Enter the actual number of days you were present in the United States during:

Enter the number of days in 2009 you claim you can exclude for purposes of the substantial presence test 

2009 2008 2007

. If the type of visa you held during any

of these years changed, attach a statement showing the new visa type and the date it was acquired.

Enter the type of U.S. visa (F, J, M, or Q) you held during: 

2005 2006 2007 2008

2003 2004

. If the type of visa you held during any

of these years changed, attach a statement showing the new visa type and the date it was acquired.

2009
Form 8843 (2009) Page 2

Individuals With a Medical Condition or Medical Problem

b

c

18

Describe the medical condition or medical problem that prevented you from leaving the United States 

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 

Enter the date you actually left the United States 

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

Professional Athletes

15

16

Enter the name of the charitable sports event(s) in the United States in which you competed during 2009 and the dates of

competition 

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

Part IV

Sign here

only if you

are filing

this form by

itself and

not with

your tax

return

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.

Your signature Date

17a

Physician’s or other medical official’s signature Date

Form 8843 (2009)
Who Must File

If you are an alien individual, you must file

Form 8843 to explain the basis of your

claim that you can exclude days of

presence in the United States for

purposes of the substantial presence test

because you:

● Were an exempt individual (other than a

foreign government-related individual) or

Substantial Presence Test

You are considered a U.S. resident if you

meet the substantial presence test for

2009. You meet this test if you were

physically present in the United States for

at least:

● 31 days during 2009 and

Days of presence in the United States.

Generally, you are treated as being

present in the United States on any day

that you are physically present in the

country at any time during the day.

However, you do not count the following

days of presence in the United States for

purposes of the substantial presence test.

1. Days you regularly commuted to

work in the United States from a

residence in Canada or Mexico.

2. Days you were in the United States

for less than 24 hours when you were

traveling between two places outside the

United States.

4. Days you were unable to leave the

United States because of a medical

condition or medical problem that arose

while you were in the United States.

test, an exempt individual includes

anyone in the following categories.

● A teacher or trainee (defined on this

page).

● A student (defined on this page).

● A professional athlete temporarily

present in the United States to compete

in a charitable sports event.

Part II—Teachers and

Trainees

If you were a teacher or trainee under a

“J” or “Q” visa, you are considered to

have substantially complied with the visa

requirements if you have not engaged in

activities that are prohibited by U.S.

immigration laws that could result in the

loss of your “J” or “Q” visa status.

Even if you meet these requirements,

you cannot exclude days of presence in

2009 as a teacher or trainee if you were

exempt as a teacher, trainee, or student

for any part of 2 of the 6 prior calendar

years. But see the Exception below.

● Were unable to leave the United States

because of a medical condition or

medical problem.

● 183 days during the period 2009, 2008,

and 2007, counting all the days of

physical presence in 2009 but only 1/3

the number of days of presence in 2008

and only 1/6 the number of days in 2007.

2. A foreign employer paid all your

compensation during 2009.

compensation during each o

6 years you were present in 

States as a teacher or trainee

For more details, see Pub. 

Tax Guide for Aliens.

Note. To claim the closer connection to a

foreign country(ies) exception to the

substantial presence test described in

Regulations section 301.7701(b)-2, you

must file Form 8840, Closer Connection

Exception Statement for Aliens.

● An individual temporarily present in

the United States as a foreign

government-related individual.

1. You were exempt as a teacher,

trainee, or student for any part of 3 (or

fewer) of the 6 prior calendar years.

Alien individuals with “Q” visas are

treated as students, teachers, or trainees

and, as such, are exempt individuals for

purposes of the substantial presence test

if they otherwise qualify. “Q” visas are

issued to aliens participating in certain

international cultural exchange programs.

A teacher or trainee is an individual who

is temporarily present in the United States

under a “J” or “Q” visa (other than as a

student) and who substantially complies

with the requirements of the visa.

Note. You can download forms and

publications from the IRS website at

www.irs.gov.

If you qualify to exclude d

presence as a student, com

and III of Form 8843. If you 

visa, complete Part I and on

through 14 of Part III. On lin

the name, address, and tele

number of the director of the 

exchange program in which 

participated.

Part III—Students

If you were a student und

“J,” “M,” or “Q” visa, you ar

to have substantially compli

visa requirements if you hav

engaged in activities that are 

by U.S. immigration laws an

result in the loss of your visa 

1. Whether you have main

closer connection to a foreig

than to the United States (fo

see Pub. 519) and

2. Whether you have take

steps to change your status 

nonimmigrant to lawful perm

resident.

If you meet this exception, 

attach information to verify th

employer paid all the compe

received in 2009 and all prio

you were present in the Unite

a teacher or trainee.

Even if you meet these req

you cannot exclude days of 

2009 as a student if you we

a teacher, trainee, or studen

part of more than 5 calenda

unless you establish that yo

intend to reside permanently 

United States. The facts and

circumstances to be conside

determining if you have dem

intent to reside permanently 

United States include, but a

to:

A student is an individual wh

temporarily present in the U

under an “F,” “J,” “M,” or “Q

who substantially complies w

requirements of the visa.

3. Days you were temporarily in the

United States as a regular crew member of

a foreign vessel engaged in transportation

between the United States and a foreign

country or a possession of the United

States unless you otherwise engaged in

trade or business on such a day.

If you qualify to exclude days of

presence as a teacher or trainee,

complete Parts I and II of Form 8843. If

you have a “Q” visa, complete Part I and

only lines 6 through 8 of Part II. On line

6, enter the name, address, and

telephone number of the director of the

cultural exchange program in which you

participated.

Exception. If you were exempt as a

teacher, trainee, or student for any part of

2 of the 6 prior calendar years, you can

exclude days of presence in 2009 as a

teacher or trainee only if all four of the

following apply.
present in the United States as a

professional athlete or because of a

medical condition or medical problem

that arose while you were in the United

States. Failure to exclude days of

presence in the United States could

result in your being considered a U.S.

resident under the substantial presence

test.

You will not be penalized if you can

show by clear and convincing evidence

that you took reasonable actions to

become aware of the filing requirements

and significant steps to comply with

those requirements.

When and Where To File

If you do not have to file a 2009 tax

return, mail Form 8843 to the

Department of the Treasury, Internal

Revenue Service Center, Austin, TX

73301-0215 by the due date (including

extensions) for filing Form 1040NR or

Form 1040NR-EZ.

Part V—Individuals With a

Medical Condition or

Medical Problem

For purposes of the substantial presence

test, do not count the days you intended

to leave the United States but could not

do so because of a medical condition or

medical problem that arose while you

were in the United States. Whether you

intended to leave the United States on a

particular day is determined based on all

the facts and circumstances. For more

details, see Pub. 519.

If you qualify to exclude days of

presence because of a medical

condition or medical problem, complete

Part I and lines 17a through 17c. Have

your physician or other medical official

complete line 18.

Paperwork Reduction Act Notice. We ask for the information on this fo

out the Internal Revenue laws of the United States. Section 7701(b) and 

regulations require that you give us the information. We need it to determ

can exclude days of presence in the United States for purposes of the s

presence test.

The average time and expenses required to complete and file this form 

depending on individual circumstances. For the estimated averages, see 

instructions for your income tax return.

You are not required to provide the information requested on a form th

to the Paperwork Reduction Act unless the form displays a valid OMB co

number. Books or records relating to a form or its instructions must be re

long as their contents may become material in the administration of any 

Revenue law. Generally, tax returns and return information are confidenti

required by section 6103.

If you are filing a 2009 Form 1040NR or

Form 1040NR-EZ, attach Form 8843 to

it. Mail your tax return by the due date

(including extensions) to the address

shown in your tax return instructions.

not required to complete line

3b of Form 8843 if you provi

requested information on the

corresponding lines of Form 

1040NR-EZ. In this case, ent

"Information provided on For

or "Information provided on F

1040NR-EZ" on lines 1 throu

Form 8843.

Line 1b. Enter your current

nonimmigrant status, such as 

shown on your current Immig

I-94, Arrival-Departure Recor

status has changed while in 

States, enter the date of cha

If you have suggestions for making this form simpler, we would be hap

from you. See the instructions for your income tax return.

United States to compete in a charitable

sports event. For details on charitable

sports events, see Pub. 519.

If you qualify to exclude days of

presence as a professional athlete,

complete Parts I and IV of Form 8843.