Yearly Forms for the U.S. and Oregon Governments
out a form to show you are exempt. This form can be
Part I General Information
1a Type of U.S. visa (for example, F, J, M, Q, etc.) and date you entered the United States
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J-1 March 15, 2018
b Current nonimmigrant status. If your status has changed, also enter date of change and previous status. See instructions.
2 Of what country or countries were you a citizen during the tax year?
Japan
3a What country or countries issued you a passport?
Japan
b
Enter your passport number(s)
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XS1234567
4a Enter the actual number of days you were present in the United States during:
2019
353
2018
291
2017
b Enter the number of days in 2019 you claim you can exclude for purposes of the substantial presence test
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Part II Teachers and Trainees
5
For teachers, enter the name, address, and telephone number of the academic institution where you taught in 2019
▶
6
For trainees, enter the name, address, and telephone number of the director of the academic or other specialized program
you participated in during 2019
▶
7
Enter the type of U.S. visa (J or Q) you held during:
▶
2013 2014
2015 2016 2017 2018
. 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.
8
Were you present in the United States as a teacher, trainee, or student for any part of 2 of the 6 prior
calendar years (2013 through 2018)? . . . . . . . . . . . . . . . . . . . . . . . . Yes No
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, address, and telephone number of the academic institution you attended during 2019
▶
University of Oregon 1217 University of Oregon Eugene, OR 97403-1217 (541) 346-3206
10
Enter the name, address, and telephone number of the director of the academic or other specialized program you participated
in during 2019
▶
Dr. Cheryl Ernst, 1787 University of Oregon, Eugene OR 97403-1787 (541) 346-3945
11
Enter the type of U.S. visa (F, J, M, or Q) you held during:
▶
2013 2014
2015 2016 2017 2018
J
. 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.
12
Were you present in the United States as a teacher, trainee, or student for any part of more than 5 calendar
years? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
If you checked the “Yes” box on line 12, you must provide sufficient facts on an attached statement to
establish that you do not intend to reside permanently in the United States.
13
During 2019, 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? . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
□
No
□
No