Research Corporation of the University of Hawaiʻi

DISB WH-1
(REV 04/29/20 ADA)
UNIVERSITY OF HAWAII
STATEMENT OF CITIZENSHIP AND FEDERAL TAX STATUS
PURPOSE:
This form is for individuals. To comply with applicable tax provisions of the Internal Revenue Service (IRS) regulations, the information requested on this form is required to determine the appropriate federal tax withholding and is required for each calendar year. (Business entities should use IRS Form W-9)
DIRECTIONS:
UNITED STATES (US) CITIZENS: 1. Complete Sections A and E only.
PERMANENT RESIDENT ALIENS:
1. Complete Sections A and E only.
2. Attach a photocopy (front and back) of your Alien Registration Card.
ALL OTHERS:
1. Complete Sections A, B, C, and E.
2. Complete Section D if applicable.
3. Submit copy of your electronic I-94 Passport ID Page and Visa page.
4. Submit IRS Form W8-BEN for foreign status.
5. For J-1 visaholders, submit copy of DS-2019.
6. For B visaholders, submit DISB-45.
7. For F-1 visaholders, submit copy of I-20.
8. Submit IRS Form 8233 if performing services as independent contractor (Treaty only).
Section A. PERSONAL INFORMATION
1. General Information
Last Name First Middle
US Social Security Number or ITIN Number
Country of Citizenship
Country of Residence for Tax Purpose
E-Mail Address
[FOR NON-UH PERSONNEL] Are you a PostDoc? [ ] YES [ ] NO
Are you employed anywhere? [ ] YES [ ] NO If you answered “YES”, please provide your employer’s information: Employer’s Name Number & Street City/Province State Postal Code
2. US Mailing Address
Number and Street City State Zip Code
3. Foreign Mailing Address
Number and Street City/Province Country Postal Code
Section B. US IMMIGRATION ACTIVITY
1. Current Visa Status
Date of US Entry
Expiration Date of Current Visa
Intended Length of Stay (Days)
Anticipated Departure Date
Current Visa Type (check appropriate box):
[ ] F-1 Student
[ ] J-1 Student
[ ] J-1 Visitor (Non-Student)
[ ] B-1/WB Visitor for Business
[ ] B-2/WT Visitor for Pleasure (Tourist)
[ ] Other INS Classification (list status):
What is the primary purpose of the visit? (check appropriate box)
[ ] Studying/Training/Research in a Degree Program
[ ] Studying/Training/Research in a Non-Degree Program
[ ] Training/Research as a Post-Doctoral Fellow
[ ] Providing Service as an Independent Contractor (e.g., consulting, conducting a workshop, etc.)
[ ] Other:
2. Is this the first time you have entered the United States? [ ] YES [ ] NO
3. Past Visa History
Provide the number of days you were or will be physically present in the United States. Note: Calendar year refers to the period January 1 – December 31.
Calendar Year
2020
2019
2018
2017
2016
2015
2014
Enter Visa Type/INS classification held while present in the US during the listed calendar year
Enter period(s) when you were or will be physically present in the US during the listed calendar year. (list dates as mm/dd/yy, e.g., 01/01/12 – 12/31/12
Number of days present in the United States?
Are you leaving the US this year? [ ] YES [ ] NO
Have you taken any treaty benefits during the listed year?
[ ] YES [ ] NO
[ ] YES [ ] NO
[ ] YES [ ] NO
[ ] YES [ ] NO
[ ] YES [ ] NO
[ ] YES [ ] NO
[ ] YES [ ] NO
Section C. Tax Status Determination
STEP 1: Complete the Substantial Presence Test (SPT) by completing the table below. For F, J, M or Q Visaholders, please note the following:
• For F, J, or M Student Visaholders: Do NOT count any days during your first 5 years in the United States in which you held an F, J, or M student visa.
• For J or Q Non-Student Visaholders: Do NOT count any days during your first 2 years in the previous 6 years in the United States in which you held a J or Q Non-Student visa.
CALENDAR YEAR
2020
2019
2018
ENTER TOTAL NUMBER OF DAYS YOU WERE OR WILL BE PRESENT IN THE UNITED STATES FOR EACH YEAR (A)
RATIO (B)
1
1/3
1/6
TOTAL # OF DAYS
CALCULATE TOTAL NUMBER OF DAYS TO COUNT FOR EACH YEAR (A X B)
STEP 2: Please answer the following questions:
A. Does the TOTAL NUMBER OF DAYS TO COUNT for the current calendar year equal to 31 days or more? [ ] YES [ ] NO
B. Does the TOTAL # OF DAYS for all three years equal to 183 days or more? [ ]YES [ ]NO
STEP 3: Determine your tax status:
• If you marked “YES” to both questions A and B, then you passed the Substantial Presence Test and will be treated as a RESIDENT ALIEN (RA) FOR TAX PURPOSES for this calendar year. Go to and sign Section E below.
• If you marked “No” to one or both questions, then you did not pass the Substantial Presence Test and will be treated as a NONRESIDENT ALIEN FOR TAX PURPOSES for this calendar year. Go to Section D below.
Section D. EXEMPTION FROM WITHHOLDING FOR THE NONRESIDENT ALIEN
1. All Payments made to Nonresident Aliens are subject to US federal tax withholding at a statutory rate of 30%.
However, you may claim an exemption from withholding or reduced rate via a US Tax Treaty if you meet the following requirements:
a. You must be a resident of a country that has a tax treaty with the US. (Consult IRS Publication 901, US Tax Treaties, at http://www.irs.gov/pub/irs-pdf/p901.pdf. The tax treaty must have a treaty article applicable to the type of payment you’ll be receiving:
• Scholarship or Fellowship Article for Scholarship, Fellowship, Traineeship, and Stipend Payments. OR
• Independent Personal Services Article for Fee for Services, Honoraria, and Reportable Travel payments.
b. You must meet all requirements regarding residency, time, and dollar limitations described in the tax treaty.
c. You must have a Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN) to claim a treaty exemption.
2. Do you want to claim a treaty exemption from US federal tax withholding? (Check one box only.)
[ ] YES I am a resident of a country that has a tax treaty with the US and has an applicable tax treaty article. Therefore, I claim exemption from US tax withholding via a US Tax Treaty with _________________________, my country of residence. I have attached one of the following IRS forms: (Consult IRS website for Forms and Instructions at http://www.irs.gov/formspubs/index.html)
• IRS Form 8233 for Fee for Services, Honoraria, and Reportable Travel payments. OR
• IRS Form W8-BEN for Scholarship, Fellowship, Traineeship, Stipend, and Royalty payments.
[ ] NO I choose not to claim a treaty exemption from US tax withholding, even though I am a resident of a country that has a tax treaty with the US and an applicable treaty article. I understand taxes will be withheld at 14% (Scholarships, Fellowship, Traineeship, or Stipend) or 30% (All other payments.).
[ ] NO I cannot claim a treaty exemption from US tax withholding because I do not meet the requirements stated in Part 1 above. I understand taxes will be withheld at 14% (Scholarships, Fellowship, Traineeship, or Stipend) or 30% (All other payments).
Section E. CERTIFICATION OF INFORMATION PROVIDED ON THIS FORM
Under penalties of perjury, I certify the information entered above is correct; and if a reduced rate of exemption from tax applies, I further certify that I have complied with all tax treaty requirements to qualify for the reduced rate. (For Resident Aliens, IRS has not notified me of backup withholding.)
Signature: Date:
Disbursing Office Use Only
Tax Status:
[ ] US Citizen
[ ] Resident Alien for Tax Purposes (SPT exp 12/____)
[ ] Permanent Resident Alien
[ ] Nonresident Alien
Vendor Code
Nonresident Withholding:
[ ] Statutory Rate of 30%
[ ] Reduced Rate of 14% or ___%
[ ] Exempt
Expiration Date
Form 8233 ______________
Form W8-BEN ______________
Form W-9 ______________
1099/1042 & WH Ind:
Initials
Date