Symposium on Research in Child Language Disorders
2014 Travel Awardee Information Form
Complete the following information and submit this form by Friday, March 21, 2014 to:
Pam Wegmuller, UW-Madison, Department of Communication Sciences and Disorders
1975 Willow Drive, Madison, WI 53706-1103, Fax: 608-262-6466, Email:
Full Legal Name:(last name, first name, middle initial)
Mailing Address for Award Check:
Award checks will be mailed to this address.
Permanent Address, if different from Mailing Address:
End-of-year tax forms will
be mailed to this address.
CITIZENSHIP Status Check which applies to you and enter additional information.
I am a U.S. citizen
I am not a U.S. citizen. My country of CITIZENSHIP is:
I meet one of the following: Substantial-Presence Test OR I have a Green Card
http://www.irs.gov/Individuals/International-Taxpayers/Substantial-Presence-Test
My country of CITIZENSHIP is a Visa Waiver County (ESTA Visa) and I will be traveling to the United States with an ESTA Visa.
RESIDENT or NONRESIDENT ALIEN Status
Where are you a resident for tax purposes? For tax purposes, it is very important you provide the country of RESIDENCE, which is not necessarily the country of CITIZENSHIP.
Check all that apply to you and enter additional information.
My country of RESIDENCY is the United States of America.
My country of RESIDENCY is:
I am in the United States on Visa type:
I will be traveling to the United States on Visa type:
U.S. Taxpayer Identification Numbers (TIN) as required by Federal law.
Check the applicable box and enter number.
Social Security Number (SSN):
Employer Identification Number (EIN):
Individual Taxpayer Identification Number (ITIN):
I have none of the above and will complete the ITIN form at the SRCLD.
If you are a U.S. Citizen or Resident Alien
You must also complete and send Form W-9 by Friday, March 21, 2014 to Pam Wegmuller. This form requires your U.S. Taxpayer Identification Number. If you have applied for a U.S. Taxpayer Identification Number but have not received it you must provide proof of application.
Form W-9: Request for Taxpayer Identification Number and Certification
http://www.irs.gov/pub/irs-pdf/fw9.pdf (PDF Form & Instructions)
If you are a Nonresident Alien, you may provide the required tax documents to Karen Andriacchi at the conference on June 12.
Rev. 2014-03