Appendix D-Federal Forms and Instructions Page 2 Form 8843 (2019) Part IV Professional Athletes 15 Enter the name of the charitable sports event(s) in the United States in which you competed during 2019 and the dates of competition ▶ 16 Enter the name(s) and employer identification number(s) of the charitable organization(s) that benefited from the sports event(s) ▶ Note: You must attach a statement to verify that all of the net proceeds of the sports event(s) were contributed to the charitable organization(s) listed on line 16. Part V 17a Individuals With a Medical Condition or Medical Problem Describe the medical condition or medical problem that prevented you from leaving the United States ▶ b Enter the date you intended to leave the United States prior to the onset of the medical condition or medical problem described on line 17a ▶ c 18 Enter the date you actually left the United States ▶ Physician's Statement: I certify that Name of taxpayer was unable to leave the United States on the date shown on line 17b because of the medical condition or medical problem described on line 17a and there was no indication that his or her condition or problem was preexisting. Name of physician or other medical official Physician's or other medical official's address and telephone number Date Physician's or other medical official's signature Under penalties of perjury, I declare that I have examined this form and the accompanying attachments, and, to the best of my knowledge and belief, they are true, correct, and complete. Your signature ▲ ▲ Sign here only if you are filing this form by itself and not with your tax return Date Form 8843 (2019) D-193