Foreign National Information Form
The Foreign National Information Form must be completed before you can receive any form of payment. All applicable questions below must be
answered. A copy of both sides of your I-94 Form “Arrival and Departure Record”, (a small white card inside your passport), a copy of your US Visa from
your passport, and a copy of your I-20 or DS-2019 (formerly IAP-66) must be attached to this form. This form must be returned before any check can
be issued by the Payroll or Accounts Payable Departments and must also be completed by anyone receiving tuition remission/scholarship.
Page 1 of 2
1.
Last or Family Name:
2.
U.S. Social Security Number:
4.
U.S. LOCAL STREET ADDRESS:
First Name:
Middle Name:
3. UM ID Number
790 _ _ _ _ _ _
5. FOREIGN RESIDENCE ADDRESS:
Address Line 2:
Address Line 2:
Address Line 3:
Address Line 3/City:
City:
Postal Code:
State:
Zip:
Providence/Region:
Foreign Country:
6.
Country of Citizenship:
7. Country that Issued Passport:
8.
Passport Number:
9. Visa Number:
10.
Have you ever had another immigration status in the United States?
Yes
No
11.
IMMIGRATION STATUS:
US Immigrant/Perm. Resident
F-1 Student
J-2 Spouse/Child
Visitor
J-1 Exchange Visitor
H-1 Temporary Employee
Other-please specify:
12. IF IMMIGRATION STATUS IS J-1, WHAT IS THE SUBTYPE? CHECK ONE:
01 Student
05 Professor
12 Research Scholar
02 Short Term Scholar
Other-please specify:
13. WHAT IS THE ACTUAL PRIMARY PURPOSE OF THE VISIT? CHECK ONE:
01 Studying in degree program
05 Observing
09 Demonstrating Special Skills
02 Studying in non-degree prog.
06 Consulting
10 Clinical Activities
03 Teaching
07 Research
11 Temporary Employee
04 Lecturing
08 Training
12 Here with Spouse
14. WHAT IS THE ORIGINAL DATE YOU ENTERED THE UNITED STATES FOR ANY PURPOSE?
15. WHAT IS THE START DATE OF YOUR CURRENT IMMIGRATION STATUS?
16. WHAT IS THE END DATE OF YOUR CURRENT IMMIGRATION STATUS PRIMARY PURPOSE?
17. INCOME PROVIDING ACTIVITY (e.g. Professor, Student Employment, etc.)?
18. WHAT TYPE OF STUDENT?
Undergraduate
Masters
Doctorate
Other-please specify:
19. MARRIED
Yes
No
SPOUSE IN USA?
Yes
No
# of Dependents?
20. IS YOUR COUNTRY OF RESIDENCE DIFFERENT FROM FOREIGN ADDRESS:
YES
NO
21. Did tax residency of foreign country end?
Yes
If yes, when (month/day/year)?
No
22. FOR CONSULTANTS/SELF EMPLOYED INDIVIDUALS:
Do you/will you have an office (fixed base) in the USA?
Yes - If yes, how many days in this tax year did you/will you have the office (fixed base)?
Days
No
I hereby certify that all the above information is true and correct. I understand that if my status changes from that which I have indicated
on this form I must submit a new Foreign National Information Form to the Payroll Department.
Signature:
email address:
Local Phone Number:
See Page 2 for completion of form
Date:
Foreign National Information Form
The Foreign National Information Form must be completed before you can receive any form of payment.
Page 2 of 2
PLEASE LIST ANY VISA IMMIGRATION ACTIVITY
Date of Entry:
Date of Exit:
Visa Immigration
Status:
Visa Type Primary Purpose
Have you taken any
Treaty Benefits?
Yes
No
I hereby certify that all the above information is true and correct. I understand that if my status changes from that which I have indicated on this form
I must submit a new Foreign National Information Form to the Payroll Department immediately.
Signature:
Local Phone Number:
Date:
Revised 01/22/13
Instructions for completing the Foreign National Information Form
1. Name: List full name
2. Social Security Number: Enter U.S. social security number, not your UM ID number. All employees must have a social security
number in order to work.
3. UM ID Number: List your UM ID Number.
4. Local Street Address: List your local mailing address, not your department's mailing address.
5. Foreign Residence Address: List your current foreign mailing address. This is where you reside in your country of citizenship.
6. Country of Citizenship
7. Country that Issued Passport: List the country that issued your passport, not the country of your citizenship.
8. Passport Number: This number is usually listed on the top right side of your passport as well as on the bottom left.
9. Visa Number: This is the number on the lower right hand side of your passport usually printed in colored ink other than black.
10. Immigration Status: Check yes or no.
11. Immigration Status: Check the type of immigration status that you currently hold.
12. Immigration Status for J1 Visa's: Check the appropriate J-1 subtype.
13. Actual Primary Activity: Check one activity.
14. Original date you entered the U.S.: Enter the first date you entered the U.S. Use an approximate date if you do not know.
15. Start date of current immigration status: Refer to your Form DS 2019 or I-20, or your visa if you do not have either forms.
16. End date of current immigration status: Refer to your Form DS 2019 or I-20, or your visa if you do not have either forms.
17. Income providing activity: Describe what type of work you will be performing, Professor, student employment, etc.
18. Type of student: Check the appropriate box.
19. Married: Check the appropriate box.
20. Country of Residence different from Foreign Address: Check the appropriate box.
21. Consultants/Self Employed Individuals: This is for individuals who are providing contract or consulting services, NOT employees.
Check the appropriate box IF this applies to you.
Complete Page 2: Visa Immigration Activity: Please list all the date you entered and left the U.S., your visa status at that time, primary
purpose, and if you had taken any treaty benefits.