Form 1042 Annual Withholding Tax Return for U.S. Source Income of

1042

Annual Withholding Tax Return for
U.S. Source Income of Foreign Persons

Form
Department of the Treasury
Internal Revenue Service

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If this is an amended return, check here .

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2011

See separate instructions.

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Employer identification number

Name of withholding agent

City or town, province or state, and country (including postal code)

If you will not be liable for returns in the future, check here

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QI/Withholding foreign partnership or trust

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For IRS Use Only
CC
RD
CAF
CR
EDC

Number, street, and room or suite no. (if a P.O. box, see instructions)

Check if you are a:

OMB No. 1545-0096

Enter date final income paid

FD
FF
FP
I
SIC
▶

NQI/Flow-through entity

(See instructions.)

Record of Federal Tax Liability (Do not show federal tax deposits here.)
Line
No.

Period
ending

Tax liability for period
(including any taxes assumed Line
No.
on Form(s) 1000)

Period
ending

Tax liability for period
(including any taxes assumed Line
No.
on Form(s) 1000)

1
7
21
7
2
15
22
15
Jan.
May
3
22
23
22
4
31
24
31
5 Jan. total
25 May total
6
7
26
7
7
15
27
15
Feb.
June
8
22
28
22
9
28
29
30
10 Feb. total
30 June total
11
7
31
7
12
15
32
15
Mar.
July
13
22
33
22
14
31
34
31
15 Mar. total
35 July total
16
7
36
7
17
15
37
15
Apr.
Aug.
18
22
38
22
19
30
39
31
20 Apr. total
40 Aug. total
61
No. of Forms 1042-S filed: a On paper
62
For all Form(s) 1042-S and 1000: a Gross income paid
63a Total tax liability (add monthly total lines from above) .
b Adjustments (see instructions) . . . . . . . . .
c Total net tax liability (combine lines 63a and 63b)
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Total paid by electronic funds transfer (or with a request
64
extension of time to file) for 2011 . . . . . . . .

Period
ending

Tax liability for period
(including any taxes assumed
on Form(s) 1000)

41
7
42
15
Sept.
43
22
44
30
45 Sept. total
46
7
47
15
Oct.
48
22
49
31
50 Oct. total
51
7
52
15
Nov.
53
22
54
30
55 Nov. total
56
7
57
15
Dec.
58
22
31
59
60 Dec. total
b Electronically
b Taxes withheld or assumed

. .
63a
63b
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for an
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64
65
65
Enter overpayment applied as a credit from 2010 Form 1042 .
66
Credit for amounts withheld by other withholding agents (see instructions)
66
67
Total payments. Add lines 64 through 66 . . . . . . . . . . . . . . . . ▶ 67
68
68
If line 63c is larger than line 67, enter balance due here . . . . . . . . . . . .
69
If line 67 is larger than line 63c, enter overpayment here . . . . . . . . . . . .
69
70
Apply overpayment on line 69 to (check one):
Credit on 2012 Form 1042 or
Refund
71
Excise tax on specified federal procurement payments included on line 63a.
(Total payments made
x 2% =
. . . . . . . . .
71
)
Yes. Complete the following.
Third Party Do you want to allow another person to discuss this return with the IRS (see instructions)?
Designee’s
Phone
Personal identification
Designee
▶
▶
name
no. ▶
number (PIN)

Paid
Preparer
Use Only

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and
belief, it is true, correct, and complete. Declaration of preparer (other than withholding agent) is based on all information of which preparer has any knowledge.
Capacity in which acting ▶
Date
Your
signature
Daytime phone number ▶
▲

Sign
Here

No

Print/Type preparer’s name

Firm’s name

Preparer’s signature

Date

PTIN

Firm's EIN ▶

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Firm’s address ▶

For Privacy Act and Paperwork Reduction Act Notice, see instructions.

Check
if
self-employed
Phone no.

Cat. No. 11384V

Form 1042 (2011)