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, 1995, or other tax year

beginning , 1995, and ending , 19 .

OMB No. 1545-1411

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

Enter the type of U.S. visa (e.g., F, J, M, etc.) and visa number, if any, you held during 1995 and the date it was acquired ©

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

What country issued you a passport?

Enter your passport number ©

During 1995, 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

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

in during 1995 ©

Enter the type of U.S. visa (e.g., F, J, M, etc.), if any, 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 (1989 through 1994)?

If you answered “Yes” to line 8, you cannot exclude days of presence as a teacher or trainee unless you meet the Exception

explained on page 3.

Enter the name, address, and telephone number of the academic institution you attended during 1995 ©

Yes No

Cat. No. 17227H Form 8843 (1995)

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 1995 ©

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

years?

If you answered “Yes” to 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 1995 ©

Yes No

14 If you answered “Yes” to line 13, explain ©

For use by alien individuals only.

Attachment

Sequence No. 102

1991 1992 1993 1994

1989 1990

For Privacy Act and Paperwork Reduction Act Notice, see page 3.

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 If the type of visa you held during 1995 changed, enter the new visa type and the date it was acquired ©

b

4a

b

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

Enter the number of days in 1995 you claim you can exclude for purposes of the substantial presence test ©

1995 1994 1993 .

. 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 (e.g., F, J, M, etc.), if any, you held during: ©

1991 1992 1993 1994

1989 1990

. 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.
Form 8843 (1995) 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

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 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 1995 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. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any

knowledge.

© Your signature Date ©

17a

Physician or other medical official’s signature Date

on line 17a ©
Form 8843 (1995) Page 3

General Instructions

Privacy Act and Paperwork Reduction Act Notice

We ask for the information on this form to carry out the Internal Revenue laws of the

United States. Internal Revenue Code section 7701(b) and its regulations require that

you give us the information. We need it to determine if you can exclude days of

presence in the United States for purposes of the substantial presence test. If you

do not give us the information, you may be treated as a U.S. resident for U.S.

income tax purposes.

The time needed to complete and file this form will vary depending on individual

circumstances. The estimated average time is:

Recordkeeping 13 min.

Learning about the law

or the form 5 min.

Preparing the form 29 min.

Copying, assembling, and

sending the form to the IRS 17 min.

If you have comments concerning the accuracy of these time estimates or

suggestions for making this form simpler, we would be happy to hear from you. You

can write to the Tax Forms Committee, Western Area Distribution Center, Rancho

Cordova, CA 95743-0001. DO NOT send the form to this address. Instead, see How

To File on page 4.

Section references are to the Internal

Revenue Code unless otherwise noted.

Who Must File

If you are an alien individual, you must

file Form 8843 or a similar statement 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

1995. You meet this test if you were

physically present in the United States

for at least:

● 31 days during 1995, 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.

3. Days you were unable to leave the

United States because of a medical

condition or medical problem that

developed while you were in the United

States.

4. Days you were an exempt

individual.

Exempt Individuals

For purposes of the substantial presence

test, an exempt individual includes

anyone in the following categories:

● A teacher or trainee (defined below).

● A student (defined on page 4).

● A professional athlete temporarily

present in the United States to compete

in a charitable sports event.

Teachers and Trainees (Part II)

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 and 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

1995 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 1995,

1994, and 1993, counting all the days of

physical presence in 1995 but only 1/3

the number of days of presence in 1994

and only 1/6 the number of days in

1993.

Form 8843

Parts I & II

Form 8843

Parts I & III

Form 8843

Parts I & IV

Form 8843

Parts I & V

13 min. 13 min. 13 min.

5 min. 4 min. 5 min.

34 min. 24 min. 34 min.

17 min. 17 min. 17 min.

2. A foreign employer paid all your

compensation during 1995.

3. You were present in the United

States as a teacher or trainee in any of

the 6 prior years.

4. A foreign employer paid all of your

compensation during each of those prior

6 years you were present in the United

States as a teacher or trainee.

For more details, get Pub. 519, U.S. Note: Tax Guide for Aliens. 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, or a

similar statement.

● An individual temporarily present in

the United States as a foreign

government-related individual.

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 1995

as a teacher or trainee only if all four of

the following apply.

1. You were exempt as a teacher,

trainee, or student for any part of 3 (or

fewer) of the 6 prior calendar years.

We may give this information to the Department of Justice as provided by law. We

may also give it to cities, states, and the District of Columbia for use in

administering their tax laws.

Alien individuals with “Q” visas are

treated as students, teachers, and

trainees and, as such, are exempt

individuals for purposes of the

substantial presence test if they

otherwise qualify. However, “Q” visa

holders may only exclude days of

presence after September 30, 1994. “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.

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 you

participated in.
Penalty for Not Filing Form

8843 or a Similar Statement

If you do not file Form 8843 or a similar

statement on time, you may not exclude

the days you were present in the United

States as a professional athlete or

because of a medical condition or

medical problem that developed 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.

Form 8843 (1995) Page 4

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.

Professional Athletes (Part IV)

A professional athlete is an individual

who is temporarily present in the 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.

How To File

Attach Form 8843 to your 1995 income

tax return. If you do not have to file a

return, send the form to the Internal

Revenue Service Center, Philadelphia,

PA 19255 by the due date (including

extensions) for filing Form 1040NR or

Form 1040NR-EZ. See the Instructions

for Form 1040NR or Form 1040NR-EZ.

If you qualify to exclude days of

presence as a student, complete Parts I

and III of Form 8843. If you have a “Q”

visa, complete Part I and only lines 10

through 14 of Part III. On line 10, enter

the name, address, and telephone

number of the director of the cultural

exchange program you participated in.

Individuals With a Medical

Condition or Medical

Problem (Part V)

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 developed 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.

Printed on recycled paper

Students (Part III)

If you were a student under an “F,”

“J,” “M,” 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 and could

result in the loss of your visa status. 

1. Whether you have maintained a

closer connection to a foreign country

than to the United States (for details,

see Pub. 519), and

2. Whether you have taken affirmative

steps to change your status from

nonimmigrant to lawful permanent

resident.

If you meet this exception, you must

attach information to verify that a foreign

employer paid all the compensation you

received in 1995 and all prior years that

you were present in the United States as

a teacher or trainee.

Even if you meet these requirements,

you cannot exclude days of presence in

1995 as a student if you were exempt as

a teacher, trainee, or student for any

part of more than 5 calendar years

unless you establish to the satisfaction

of the IRS district director that you do

not intend to reside permanently in the

United States. The facts and

circumstances to be considered in

determining if you have demonstrated

an intent to reside permanently in the

United States include, but are not limited

to:

A student is an individual who is

temporarily present in the United States

under an “F,” “J,” “M,” or “Q” visa and

who substantially complies with the

requirements of the visa.