Form 1042-T Annual Summary and Transmittal of Forms 1042-S

DO NOT STAPLE

Form

1042-T

OMB No. 1545-0096

Annual Summary and Transmittal of
Forms 1042-S

Department of the Treasury
Internal Revenue Service
Name of withholding agent

2011
Employer identification number

Number, street, and room or suite no.
City or town, province or state, and country (including postal code)

QI/Withholding foreign partnership or trust
NQI/Flow-through entity

If you are an intermediary (see Form 1042 instructions), check if you are a:

1a

Type of paper Forms 1042-S attached (check only one box):
Also check here if pro-rata (see instructions) ▶
b Number of paper Forms 1042-S attached ▶

Original

2a Total gross income on all paper Forms 1042-S (box 2) attached . . .
b Total federal tax withheld on all paper Forms 1042-S (box 9) attached .

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Amended

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$
$

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Caution: If you have already filed a Form 1042 and an attached Form 1042-S causes the gross income or tax withheld
information shown on your previously filed Form 1042 to change, you must file an amended Form 1042. See the
instructions below.

If this is your FINAL return, enter an “X” here (see instructions)

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Please return this entire page to the Internal Revenue Service.
Under penalties of perjury, I declare that I have examined this return and accompanying documents and, to the best of my knowledge and
belief, they are true, correct, and complete.
Your signature
▲

Sign
Here

Title

Instructions
Purpose of form. Use this form to transmit paper Forms 1042-S,
Foreign Person’s U.S. Source Income Subject to Withholding, to the
Internal Revenue Service. Use a separate Form 1042-T to transmit
each type of Form 1042-S (see the instructions for line 1a).

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If you file 250 or more Forms 1042-S, you are required to
submit them electronically. You also can use this method
to submit less than 250 Forms 1042-S. If you submit
CAUTION
Forms 1042-S electronically, do not use Form 1042-T.
See Pub. 1187, Specifications for Filing Form 1042-S, Foreign
Person's U.S. Source Income Subject to Withholding, Electronically,
for information on filing electronically.
Use of this form to transmit paper Forms 1042-S does not affect
your obligation to file Form 1042, Annual Withholding Tax Return for
U.S. Source Income of Foreign Persons.
If you have not yet filed a Form 1042 for 2011, you may send in
more than one Form 1042-T to submit paper Forms 1042-S prior to
filing your Form 1042. You may submit amended Forms 1042-S
even though changes reflect differences in gross income and tax
withheld information of Forms 1042-S previously submitted with a
Form 1042-T.
If you have already filed a Form 1042 for 2011 and an attached
Form 1042-S caused the gross income or tax withheld information
previously reported on line 62a or 62b of your Form 1042 to change,
you must file an amended Form 1042.
Where and when to file. File Form 1042-T (and Copy A of the
paper Forms 1042-S being transmitted) with the Ogden Service
Center; P.O. Box 409101; Ogden, UT 84409; by March 15, 2012.
Send the forms in a flat mailing (not folded).

Date

Daytime phone number

Identifying information at top of form. The name, address, and
EIN of the withholding agent or intermediary on this form must be
the same as those you enter on Forms 1042 and 1042-S. See the
instructions for Form 1042 for definitions of withholding agent and
intermediary.
Line 1a. You must file a separate Form 1042-T for each type of
paper Form 1042-S you are transmitting. Check only the Original or
Amended box. If you are filing pro-rata Forms 1042-S (see Form
1042-S instructions), also check the pro-rata box. As a result, there
are four possible types of Form 1042-S that may be transmitted:
• Original
• Original pro-rata
• Amended

• Amended pro-rata

Each type would be transmitted with a separate Form 1042-T. For
example, you would transmit only original Forms 1042-S with one
Form 1042-T and only amended Forms 1042-S with another Form
1042-T.
Line 2a. Enter the total of the gross income amounts shown on the
Forms 1042-S (box 2) being transmitted with this Form 1042-T.
Line 2b. Enter the total of the federal tax withheld amounts shown
on the Forms 1042-S (box 9) being transmitted with this Form
1042-T.
Final return. If you will not be required to file Forms 1042-S in the
future (on paper or electronically), enter an “X” in the “FINAL return”
box.
Paperwork Reduction Act Notice. The time needed to complete
and file this form will vary depending on individual circumstances.
The estimated average time is 12 minutes.

For more information and the Privacy Act and Paperwork Reduction Act Notice, see Form 1042-S.

Cat. No. 28848W

Form 1042-T (2011)