Revenue Procedure 87-9
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For Teachers and Researchers claiming exemption under Article 17 of the Income
Tax Treaty Between the United States and Poland.
Social Security Number:
I was a resident of Poland on the date of my arrival in the Unites States. I am not a
United States 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, giving
lectures, or conducting research at Buffalo State, which is an
accredited educational institution or scientific research institution. I will receive compensation for my teaching,
lecturing, or research activities.
The teaching, lecturing, or research compensation received during the entire tax year or during the period
qualifies for exemption
from withholding of federal tax under the tax treaty between the United States and Poland. I have not previously claimed an income tax exemption
under that treaty for income received as a teacher, lecturer,
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
(date of arrival). The treaty exemption is
available only for compensation received for a period of two (2) years
beginning on that date.
I certify that the information I have provided
above is true, correct and complete and that the above statements apply to me.