USA TAX REGISTRATION

APPLICATION FORM

CONTACT INFORMATION PLEASE PRINT IN BLOCK CAPITALS

Middle
Title: Mr Mrs Miss First Name Surname
Initial

Date of Birth dd / mm / yyyy Mobile Telephone

Email

Postal Address

Nationality How did you hear about our services?

VISA INFORMATION
Visa Type: J1 F1 H1B H2B Q L E P O Program Type: Work & Travel Intern

Tourist Other (please specify) ___________________________________ Other (please specify) ____________________________________

Date of arrival in the USA dd / mm / yyyy Date of departure from the USA dd / mm / yyyy

Have you ever filed a US tax return with the IRS before? Yes No If yes, please state for which year: __________________________________

Which tax year are you applying for now? _________________ Have you applied for this tax year before? Yes No

If you were in the US before the tax year you are applying for, it is important to provide information about those visits including visa type and days of
presence in the US - please complete the information in the grid below:

2014 2013 2012 2011 2010

Visa Type
(see list above for options)

Number of days spent in

the US

EMPLOYMENT INFORMATION

EMPLOYER 1
Company name

Address Telephone

State you worked in Final work date dd / mm / yyyy

Do you have your W2 Form? Yes No If no, would you like us to get a replacement for you?* Yes No

EMPLOYER 2
Company name

Address Telephone

State you worked in Final work date dd / mm / yyyy

Do you have your W2 Form? Yes No If no, would you like us to get a replacement for you?* Yes No

If you had more than 2 employers or any additional income from the US please include information on a separate page.

*Document retrieval fee applies

taxback.com, 333 N. Michigan Avenue, Suite 2415, Chicago, IL, 60601 www.taxback.com 2