Foreign National Questionnaire Paper Form

For foreign nationals only: Complete to be able to receive payments from the university, excluding payments for travel reimbursement and honoraria.

Foreign National Questionnaire Paper Form (PDF, 367 KB)

Submission Instructions

Mail, hand-deliver, or fax the completed form to the following address/fax number:

University Tax Office
377 Pine Tree Rd.
Ithaca, NY 14850
Fax: (607) 255-3198

Include the following documents:

1. Copies of both sides of the I-94 form "Arrival and Departure Record" (small, white card inside the passport)
2. Copy of your Visa (from your passport)
3. Form I-20 or DS-2019 (formerly IAP-66)

Form instructions are available on the Foreign National Questionnaire page.

Form Completion Instructions

• Part I: Personal Information
• Part II: U.S. Local Address
• Part III: Foreign Residence Address
• Part IV: Citizenship and Passport Information
• Part V: Current Immigration Status in U.S.
• Part VI: If Immigration Status is J-1, What is the Sub-Type?
• Part VII: What is the Actual Primary Activity of this Visit?
• Part VIII: Entry and Activity Dates
• Part IX: Income Providing Activity
• Part X: Student Type
• Part XI: Spouse Information
• Part XII: Country of Tax Residence if Different from Citizenship
• Part XIII: List Any Visits to the U.S. in the Last Three Calendar Years
• Part XIV: Certification

Part I: Personal Information

1. Last / Family Name: Enter your last name, your family name.
2. First Name: Enter your first name, not your family name.
3. Middle Name:  Enter your middle name.
4. U.S. Federal ID # (i.e. social security number): Enter the U.S. Social Security Number (SSN) issued by the U.S. Social Security Administration (SSA), not your ID number. Do not list numbers not assigned by the U.S. SSA (i.e., Canadian Social Insurance Number, etc.). All employees must have an SSN to work in the U.S. If you do not have an U.S.-issued SSN, enter your Individual Taxpayer Identification Number (ITIN) issued to you by the U.S. Internal Revenue Service (IRS).

Back

Part II: U.S. Local Address

1. Address Line 1: Enter the house number, street name, and apartment number in which you reside in the U.S.
2. Address Line 2: Enter any information used to identify your apartment/house that is not listed in the above line (if applicable, if not - leave blank).
3. Address Line 3: Enter any information used to identify your apartment/house that is not listed in the above lines (if applicable, if not - leave blank).
4. City: Enter the city in which you reside in the U.S.
5. State: Enter the state in which you reside in the U.S.
6. Zip: Enter the zip code of the city in which you reside in the U.S.

Back

Part III: Foreign Residence Address

1. Address Line 1: Enter your non-U.S. house number, street name, and apartment number in which you reside.
2. Address Line 2: Enter any information used to identify your apartment/house that is not listed in the above line (if applicable, if not - leave blank).
3. City: Enter your non-U.S. city of residence.
4. Province: Enter your province of residence (non-U.S.)
5. Country: Enter your country of residence (non-U.S.)
6. Postal Code: Enter the postal code of the country in which you reside (non-U.S.)

Back

Part IV: Citizenship and Passport Information

1. Country of Citizenship: Enter the country in which you hold citizenship.
2. Country that Issued Passport: Enter the country that issued your passport (may differ from your country of citizenship).
3. Passport #: Enter your passport number.
4. Visa # (not the control number that begins with a year): Enter your visa number, ensuring it is not the control number.

Back

Part V: Current Immigration Status in U.S.

1. Either circle one of the following selections:
   1. J-2 Spouse or Child of Exchange Visitor
   2. H-1 Temporary Employee
   3. F-1 Student
   4. J-1 Exchange Visitor
   5. U.S. Immigrant / Permanent Resident
2. Or enter your applicable U.S. immigration status in the "Other:" field.

Back

Part VI: If Immigration Status is J-1, What is the Sub-Type?

1. Either circle one of the following selections:
   1. 12 Research Scholar
   2. 05 Professor
   3. 02 Short-Term Scholar
   4. 01 Student
2. Or enter the correct information in the "Other:" field.

Back

Part VII: What is the Actual Primary Activity of This Visit?

1. Circle one of the following selections:
   1. 01 Studying in a Degree Program
   2. 02 Studying in a Non-Degree Program
   3. 03 Teaching
   4. 04 Lecturing
   5. 05 Observing
   6. 06 Consulting
   7. 07 Conducting Research
   8. 08 Training
   9. 09 Demonstrating Special Skills
   10. 10 Clinical Activities
   11. 11 Temporary Employment
   12. 12 Here with Spouse

Back

Part VIII: Entry and Activity Dates

1. Based on the information on your I-94 form, enter the actual date your entered the U.S. in the mm/dd/yyyy format (e.g., 01/21/2007)
2. Based on the information listed on your I-20 or DS-2019 (formerly IAP-66), enter the start date of your immigration status or this primary activity in the mm/dd/yyyy format (e.g., 01/21/2007)
3. Based on the information listed on your I-20 or DS-2019 (formerly IAP-66), enter the projected end (finish) date of your immigration status or this primary activity in the mm/dd/yyyy format (e.g., 01/21/2007)

Back

Part IX: Income Providing Activity

1. Enter the title of the income earning position you hold at Cornell, if applicable.

Back

Part X: Student Type

1. Either circle one of the following selections:
   1. Undergraduate
   2. Masters
   3. Doctoral
2. Or enter the information in the "Other:" field.

Back

Part XI: Spouse Information

1. "Is your spouse (husband/wife) in the U.S.?" Circle the correct answer:
   1. Yes
   2. No
2. "Number of children in the U.S.?" Enter the number of children in the U.S. with you if applicable.

Back

Part XII: Country of Tax Residence if Different from Citizenship

1. Does your country of tax residence (country where you last paid taxes) differ from the country in which you hold citizenship? If so, did your tax residency end? Circle the correct selection:
   1. ​Yes
   2. No
2. If "Yes" was selected, enter the date when the tax residency ended.

Back

Part XIII: List Any Visits to the U.S. in the Last Three Calendar Years

Note: You must also list all F, J, M, or Q visas since 1/1/1985. If necessary, attach an additional form or paper to include the required entries.

1. Be sure to enter information in all of the listed columns:
   1. Date of Entry
   2. Date of Exit
   3. Visa Status (B-1, F-1, etc.)
   4. Primary Activity (tourist, student, etc.)
   5. Have you taken any treaty benefits? Yes or No

Back

Part XIV: Certification

1. By signing the form, you are certifying the information is true and correct. You are also agreeing to submit a new form to the University Tax Office as soon as there are changes to your current (at the time of signing) visa status. Changes include, but are not limited to the following: 
   1. ​You change from a J-1 visa to a B-1B visa
   2. You receive a "green card"
2. Changes to your visa status may also change your tax liability, for which you are held personally responsible.
3. By signing this document, you agree to the conditions listed in the certification statement located above the signature field.
   1. ​Signature: Sign your full name
   2. Date: Enter the current date
   3. Local Phone: Enter a local phone number where you can be contacted
   4. E-mail: Enter the email address Cornell assigned you

Back