University of Louisiana at Lafayette
Student - Foreign National Data Form
IDENTIFICATION OF PAYEE
Name (Last, First, Middle) UL ID Number Taxpayer ID Number
Foreign Tax ID (if applicable) Email Address:
Street Address in U.S. Permanent Residence Address
Street Address Line 2 Street Address Line 2
City, State, Zip Code City, Province, Country, Postal Code
Country of Citizenship Country that issued passport
Passport # Passport Expiration Date (mm/dd/year)
Visa #
UNIVERSITY STATUS (Check all that apply)
☐Scholarship/Fellowship □ graduate □ Other ☐Work performed outside U.S.
recipient assistantship
TYPE OF PAYMENT RECEIVING
☐Non-qualified Scholarship (housing, COA, insurance) ☐Student Travel Grant or reimbursement (GSO)
☐Participant Support Stipend ☐Award/Prize
☐Other
IMMIGRATION STATUS INFORMATION- (check one)
□ J1 ☐student If you are not a student/researcher/teacher sponsored by the University of Louisiana at
☐other Lafayette, please provide written authorization from the responsible officer (RO) of your
designated sponsor.
☐F1 If you are not a student sponsored by the University of Louisiana at Lafayette, please
provide written authorization from the responsible officer (RO) of your designated
sponsor.
☐Permanent Resident
DAYS PRESENT - List any F, J, M or Q visa immigration activity since January 1, 1985. All other visa
immigration activity only for the past three calendar years
Date of US Entry Date of US Exit Did you take treaty benefits?
month/day/year month/day/year Visa status / J1 category Primary Activity
☐Yes □ No
☐Yes □ No
☐Yes □ No
☐Yes □ No
☐Yes □ No
☐Yes □ No
☐Yes □ No
☐Yes □ No
☐Yes □ No
RESIDENCY
What country did you live in just prior to this visit to the U.S.?
Did you pay taxes as a resident of that country? (If you did not pay taxes in your home country only ☐yes ☐no
because you did not earn enough income or because you were in school, answer ‘‘yes’’ that you paid taxes.)
Did your tax residency in that country end prior to this visit to the U.S.? ☐yes ☐no
If yes, when? _ (mm/dd/year)
Under penalties of perjury, I certify that all the information on this form is true and correct. I understand
that if my status changes, I must submit a new form.
Signature: Date:
I grant permission to the University of Louisiana at Lafayette to use my passport information to access my I94
record from the Department of Homeland Security website (https://i94.cbp.dhs.gov/I94) in connection with
employment and tax matters.
Signature: Date:
IDENTIFICATION OF PAYEE TYPE OF PAYMENT RECEIVED
• Name --- Enter your full name. • Non-qualified scholarship --- Payments that are used for
• UL ID Number --- University employees/ students enter your 9 digit expenses such as room, board, travel and personal expenses.
ULID. May be subject to tax withholding.
• Taxpayer ID --- Enter your social security number, individual
taxpayer identification number, or employer identification number.
• Student travel grant or reimbursement- Reimbursement to a
student who is traveling as part of their study and not as an
• Department --- Enter the name of the department that is employee of the university.
compensating you.
• Email Address --- Enter your email address • Award / Prize --- Payment in recognition of an achievement or
as a result of entering a contest. Prizes and awards are always
• Street Address in U.S. --- Enter your current mailing address in U.S.
taxable.
• Permanent Residence Address --- Enter your permanent address in
the country where you claim to be a resident for purposes of that • Participant Support Stipend --- Payments provided to a study
country’s income tax. (Do not use a University address or post participant or to a workshop attendee. CANNOT be employee
office box address.
• University Status --- Check all that apply.
• Type of Payment Received --- check the type of payment you will be
receiving.
IMMIGRATION STATUS INFORMATION DAYS PRESENT
• J1- If the University of Louisiana at Lafayette is not who sponsored • This information will be used to calculate substantial
your visa you will need to provide written authorization from the presence test (SPT).
responsible officer (RO) of your designated sponsor in order to • Enter the date you arrived in the US for each Visa
receive payment. immigration activity. (do not count exit dates for
• F1- A non-immigrant visa for those wishing to study in the U.S. If vacation/holiday)
the University of Louisiana at Lafayette is not who sponsored your • List the primary activity/reason you were issued the visa.
visa you will need to provide written authorization from the (i.e student, researcher, etc)
responsible officer (RO) of your designated sponsor in order to
receive payment.
• We have listed only the most common visa types; if you have
something else please indicate it in the ‘‘other’’ blank.
