8843-21

2021 8843 Statement for Exempt Individuals and Individuals With a Medical Condition For use by alien individuals only.
Name

Your first name and initialLast 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
1a Type of U.S. visa (for example, F, J, M, Q, etc.)
1a Date you entered the United States

MonthDayYear
Date
b Current nonimmigrant status.
b If your status has changed, enter date of change and previous status.

MonthDayYear
Date
b Previous status(if applicable)
2 Of what country or countries were you a citizen during the tax year?
3a What country or countries issued you a passport?
b Enter your passport number(s)
4a Enter the actual number of days you were present in the United States during:
2021
2020
2019
b Enter the number of days in 2021 you claim you can exclude for purposes of the substantial presence test
Teachers and Trainees
5 For teachers, enter the name and address of the academic institution where you taught in 2021
5 For teachers, enter telephone number of the academic institution where you taught in 2021
6 For trainees, enter the name and address of the director of the academic or other specialized program you participated in during 2021
6 For trainees, enter telephone number of the director of the academic or other specialized program you participated in during 2021
Enter the type of U.S. visa (J or Q) you held during:
2015
2016
2017
2018
2019
2020
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. If yes, please explain and/or upload copy of document.

YesNo
x for yes
x for no
Please Explain
File Upload

Cancelof
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 and address of the academic institution you attended during 2021
9 Enter the telephone number of the academic institution you attended during 2021
10 Enter the name and address of the director of the academic or other specialized program you participated in during 2021
10 Enter the telephone number of the director of the academic or other specialized program you participated in during 2021
Enter the type of U.S. visa (F, J, M, or Q) you held during:
2015
2016
2017
2018
2019
2020
Please Explain
File Upload

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

YesNo
x for yes
x for no
13 During 2021, 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?

YesNo
x for yes
x for no
14 If you checked the "Yes" box on line 13, explain
Professional Athletes
15 Enter the name of the charitable sports event(s) in the United States in which you competed during 2021
15 Enter the dates of competition of the charitable sports event(s) in the United States in which you competed during 2021

MonthDayYear
Date
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.
Individuals With a Medical Condition or Medical Problem
17a Describe the medical condition or medical problem that prevented you from leaving the United States. See instructions.
17b Enter the date you intended to leave the United States prior to the onset of the medical condition or medical problem described
c Enter the date you actually left the United States
I certify that
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
Sign here only if you are filing this form by itself and not with your tax return
Signature
Date

MonthDayYear
Date

2021 8843 Statement for Exempt Individuals and Individuals With a Medical Condition For use by alien individuals only.

Teachers and Trainees

Part III Students

Professional Athletes

Individuals With a Medical Condition or Medical Problem