ࡱ> >@=` $bjbj 4(E 8  $0{Z< $h-Qdw{ddOdXd [K dTe0, 0h1HycE111PX111ddddD2 d2   Please Print: LAST NAMEFIRST NAMESOCIAL SECURITY NUMBER FORMTEXT       FORMTEXT       FORMTEXT       For TEACHERS and RESEARCHERS Claiming exemption under Article 21(5) of the Income Tax Treaty Between the United States and the Czech Republic For Calendar Year 20 FORMTEXT    I was a resident of the Czech Republic on the date of my arrival in the United States. I am not a U.S. citizen. I have not been lawfully accorded the privilege of residing permanently in the United States as an immigrant. I am visiting the United States for the purpose of teaching or conducting research for a period not expected to exceed two years at the 챬, Baltimore, which is a recognized educational institution. I will receive compensation for my teaching or research activities. The teaching or research compensation received during the entire tax year (or for the portion of the year from  FORMTEXT       to  FORMTEXT      ) qualifies for exemption from withholding of federal tax under the tax treaty between the United States and the Czech Republic. I have not previously claimed an income tax exemption under this treaty for income received as a teacher, researcher, or student before the date of my arrival in the United States. Any research I perform will be undertaken in the public interest and not primarily for the private benefit of a specific person or persons. I arrived in the United States on  FORMTEXT z| . d t ~ }tkek\eVe hp9CJhs5CJ\ h~CJh~5CJ\hP-5CJ\ hP-CJ'jwhP-h 5B*Uph'jhP-h 5B*UphhP-hP-5B*ph&jhP-5B*UmHnHphu'jhP-h 5B*UphhP-5B*phjhP-5B*UphhP-h~! 4Jxzk_ $$Ifa$gdP-kd$$IflF $x x x 06    4 la $Ifgd gdP-$a$ "$2  ` b d   |wrrrrpph_$h^ha$$ & Fa$$a$gdP-kd$$IflF $x x x 06    4 la  : > @ T V X \ ^  2 ƭՔՐxq^P:*jhP-h 5>*B*UphhP-hP-5>*B*ph$jhP-hP-5>*B*Uph h&?5\hWNh&?5h&?hlFhp95hp9h~0jhP-5>*B*CJU\mHnHphu1jhP-h 5>*B*CJU\phhP-5>*B*CJ\ph%jhP-5>*B*CJU\phhTv5CJ\ h~CJhlF5CJ\ 2 3 TU"""" """""""J""""## $h^ha$gd3 gdP-$a$$h^ha$$ & Fa$$a$ $ & Fa$gd&?   *,.8:8 !!"" " """""""#h$t$v$$$$$íѩÓщс}}}}yuqu}hP-hKh3 h jh UhTvh~5U*j~hP-h 5>*B*Uphhp9*jhP-h 5>*B*UphhP-hP-5>*B*phh~/jhP-hP-5>*B*UmHnHphu$jhP-hP-5>*B*Uph(      (date of my last arrival in the United States before beginning the teaching or research services for which exemption is claimed). The treaty exemption is available only for compensation received during a period of two years beginning on that date.     REVENUE PROCEDURE 87-9 TAX TREATY REPRESENTATION LETTER Under penalties of perjury, to the best of my knowledge and belief, I certify that the statements above, are true, correct, and complete. ________________________________________________ _______________________ Signature Date Rev. 10/05 (UMB) ##:$f$h$$$$$$h^ha$$a$gdj<h^h21h:pP-/ =!"#$% $$If!vh5x 5x 5x #vx :V l065x 4tDText1tDText2D Text3 ###-##-####$$If!vh5x 5x 5x #vx :V l06,5x 4xDText4##DText5M/d/yyEnter date in format m/d/yyDText6M/d/yyEnter date in format m/d/yyDText7M/d/yyEnter date in format m/d/yyH@H Normal CJOJQJ_HaJmH sH tH DAD Default Paragraph FontVi@V  Table Normal :V 44 la (k@(No List N%@N Envelope ReturnCJOJQJ^JaJl$@l Envelope Address!@ &+D/^@ CJOJQJ^J4@4 Header  !4 @"4 Footer  !(%<=Qeyz{ 01223 00@0@0 @0 @0 @0 0 0 0 0 @0000000 00 00 00 00 000y00Vy00y00Vy00y00Vy00y00Vy00@0@0@0y00V@0@0@0@0@0@0@0y00y00x'%<=Qeyz{ 0122 0{00hy00y00{00{00{00y000000000 00 0 00 FFDDDG $  #$ $ =IOQ]ceqw+.FFFFFFF8@0(  B S  ?Text1Text2Text3Text4Text5Text6Text7=Qe Pdx/ |# ʽ )T4t( G B  |&  tċD./  T€\À4Āŀ̀ƀ&ǀl& JPz%'==C        OX24BKK  B*urn:schemas-microsoft-com:office:smarttagscountry-regionh *urn:schemas-microsoft-com:office:smarttagsCity0http://www.5iamas-microsoft-com:office:smarttagsZ*urn:schemas-microsoft-com:office:smarttags PlaceNamehttp://www.5iantlavalamp.com/=*urn:schemas-microsoft-com:office:smarttags PlaceTypeV*urn:schemas-microsoft-com:office:smarttagsplacehttp://www.5iantlavalamp.com/    3{ /FX29K22  tjh^`.h^`.hpLp^p`L.h@ @ ^@ `.h^`.hL^`L.h^`.h^`.hPLP^P`L.t         3 |Tv P-j<&?5@lFJH ?KIXLdp[vsnoK~p9%<=Qeyz @46@{Lpp p@pp @p UnknownG: Times New Roman5Symbol3& : Arial5& zaTahomaCFComic Sans MS"1hUR&!tpZ   _-!4d 2QHX?[v*For TEACHERS and RESEARCHERS Susan McKechnieSusan Beckerman Oh+'0 ,8 X d p | For TEACHERS and RESEARCHERS Susan McKechnieNormalSusan Beckerman10Microsoft Office Word@V@h^@F9@&w՜.+,0 hp|    For TEACHERS and RESEARCHERS Title  !"#$%&'()*+,./012346789:;<?Root Entry FTAData 1TableWordDocument4(SummaryInformation(-DocumentSummaryInformation85CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q