Form 8843

Department of the Treasury 

Internal Revenue Service

Statement for Exempt Individuals and Individuals 

With a Medical Condition

For use by alien individuals only.

▶ Information about Form 8843 and its instructions is at www.irs.gov/form8843.

For the year January 1—December 31, 2012, or other tax year

beginning , 2012, and ending , 20 .

OMB No. 1545-0074

2012

Attachment 

Sequence No. 102

Your first name and initial Last name Your U.S. taxpayer identification number, if any

Fill in your 

addresses only if 

you are filing this 

form by itself and 

not with your tax 

return

Address in country of residence Address in the United States

Part I General Information

1a Type of U.S. visa (for example, F, J, M, Q, etc.) and date you entered the United States ▶

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

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

3a What country issued you a passport?

b Enter your passport number ▶

4a Enter the actual number of days you were present in the United States during:

2012 2011 2010

b Enter the number of days in 2012 you claim you can exclude for purposes of the substantial presence test ▶

Part II Teachers and Trainees

5 For teachers, enter the name, address, and telephone number of the academic institution where you taught in 2012 ▶

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

you participated in during 2012 ▶

7 Enter the type of U.S. visa (J or Q) you held during: ▶ 2006 2007

2008 2009 2010 2011 . 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.

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

calendar years (2006 through 2011)? . . . . . . . . . . . . . . . . . . . . . . . . Yes No

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 in the instructions.

Part III Students

9 Enter the name, address, and telephone number of the academic institution you attended during 2012 ▶

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

in during 2012 ▶

11 Enter the type of U.S. visa (F, J, M, or Q) you held during: ▶ 2006 2007

2008 2009 2010 2011 . 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.

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

years? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

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.

13 During 2012, 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? . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

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

For Paperwork Reduction Act Notice, see page 4. Cat. No. 17227H Form 8843 (2012)
Form 8843 (2012) Page 2

Part IV Professional Athletes

15 Enter the name of the charitable sports event(s) in the United States in which you competed during 2012 and the dates of 

competition ▶

16 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 Individuals With a Medical Condition or Medical Problem

17a Describe the medical condition or medical problem that prevented you from leaving the United States ▶

b 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 ▶

c Enter the date you actually left the United States ▶

18 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

Physician’s or other medical official’s signature Date

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

Form 8843 (2012)
Form 8843 (2012) Page 3

General Instructions

Section references are to the Internal 

Revenue Code unless otherwise 

specified.

Future Developments

For the latest information about 

developments related to Form 8843 and 

its instructions, such as legislation 

enacted after they were published, go to

www.irs.gov/form8843.

Who Must File

If you are an alien individual (other than a 

foreign government-related 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, or

• Were unable to leave the United States 

because of a medical condition or 

medical problem.

When and Where To File

If you are filing a 2012 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.

If you do not have to file a 2012 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.

Penalty for Not Filing 

Form 8843

If you do not file Form 8843 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 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.

Substantial Presence Test

You are considered a U.S. resident if you 

meet the substantial presence test for 

2012. You meet this test if you were 

physically present in the United States 

for at least:

• 31 days during 2012 and

• 183 days during the period 2012, 2011, 

and 2010, counting all the days of 

physical presence in 2012 but only 1/3 

the number of days of presence in 2011 

and only 1/6 the number of days in 2010.

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.

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 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.

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.

5. 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 on this 

page).

• A student (defined on the next page).

• A professional athlete temporarily 

present in the United States to compete 

in a charitable sports event.

The term exempt individual also 

includes an individual temporarily 

present in the United States as a foreign 

government-related individual under an 

“A” or “G” visa. If you are present under 

an “A” or “G” visa, you are not required 

to file Form 8843.

Specific Instructions

Part I—General Information

If you are attaching Form 8843 to Form 

1040NR or Form 1040NR-EZ, you are 

not required to complete lines 1a 

through 4a of Form 8843 if you provide 

the requested information on the 

corresponding lines of Form 1040NR or 

1040NR-EZ. In this case, enter 

“Information provided on Form 1040NR” 

or “Information provided on Form 

1040NR-EZ” on line 1a of Form 8843.

Line 1b. Enter your current

nonimmigrant status, such as that shown 

on your current Immigration Form I-94, 

Arrival-Departure Record. If your status 

has changed while in the United States, 

enter the date of change.

Part II—Teachers and 

Trainees

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 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 

2012 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.

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 2012 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.

2. A foreign employer paid all your 

compensation during 2012.

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, see Pub. 519, U.S. 

Tax Guide for Aliens.
Form 8843 (2012) Page 4

If you meet this exception, you must 

attach information to verify that a foreign 

employer paid all the compensation you 

received in 2012 and all prior years that 

you were present in the United States as 

a teacher or trainee.

Part III—Students

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.

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. 

Even if you meet these requirements, 

you cannot exclude days of presence in 

2012 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 that you do not intend to reside 

permanently in the United States. The 

facts and circumstances to be 

considered in determining if you have 

established that you do not intend to 

reside permanently in the United States 

include, but are not limited to:

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 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 in which you 

participated.

Part IV—Professional 

Athletes

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.

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 of Part V. Have 

your physician or other medical official 

complete line 18.

Paperwork Reduction Act Notice. We 

ask for the information on this form to 

carry out the Internal Revenue laws of 

the United States. 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.

You are not required to provide the 

information requested on a form that is 

subject to the Paperwork Reduction Act 

unless the form displays a valid OMB 

control number. Books or records 

relating to a form or its instructions must 

be retained as long as their contents 

may become material in the 

administration of any Internal Revenue 

law. Generally, tax returns and return 

information are confidential, as required 

by section 6103.

The average time and expenses 

required to complete and file this form 

will vary depending on individual 

circumstances. For the estimated 

averages, see the instructions for your 

income tax return.

If you have suggestions for making 

this form simpler, we would be happy to 

hear from you. See the instructions for 

your income tax return.