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

Version B, Cycle 9

1042

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

Form
Department of the Treasury
Internal Revenue Service

▶

OMB No. 1545-0096

2014

Information about Form 1042 and its separate instructions is at www.irs.gov/form1042.

If this is an amended return, check here .

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Employer identification number

Name of withholding agent

Ch. 3 Status Code

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

City or town, province or state, country, and ZIP or foreign postal code

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For IRS Use Only
CC
RD
CAF
CR
EDC

Ch. 4 Status Code

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FD
FF
FP
I
SIC

If you do not expect to file this return in the future, check here ▶
Enter date final income paid ▶
Check here if you made quarter-monthly deposit using the 90% rule (see Instructions for deposit requirements) ▶

Section 1
Line
No.

Period
ending

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
61
62

Record of Federal Tax Liability (Do not show federal tax deposits here)
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)

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

Period
ending

7
21
7
41
7
15
22
15
42
15
Jan.
May
Sept.
22
23
22
43
22
31
24
31
44
30
Jan. total
25 May total
45 Sept. total
7
26
7
46
7
15
27
15
47
15
Feb.
June
Oct.
22
28
22
48
22
28
29
30
49
31
Feb. total
30 June total
50 Oct. total
7
31
7
51
7
52
15
15
32
15
Mar.
July
Nov.
53
22
22
33
22
54
30
31
34
31
55 Nov. total
Mar. total
35 July total
56
7
7
36
7
57
15
15
37
15
Apr.
Aug.
Dec.
58
22
22
38
22
59
31
30
39
31
60 Dec. total
Apr. total
40 Aug. total
No. of Forms 1042-S filed: a On paper
b Electronically
Total gross amounts reported on all Forms 1042-S and 1000:
a Total U.S. source FDAP income (other than U.S. source substitute payments) reported . . . . .
62a
b Total U.S. source substitute payments reported:
(1) Total U.S. source substitute dividend payments reported . . . . . . . . . . . . . . 62b(1)
(2) Total U.S. source substitute payments reported other than substitute dividend payments . . . 62b(2)
c Total gross amounts reported (Add lines 62a-b) . . . . . . . . . . . . . . . . .
62c
d Enter gross amounts actually paid if different from gross amounts reported . . . . . . . . .
62d
Do you want to allow another person to discuss this return with the IRS (see instructions)?
Yes. Complete the following.
Third Party
Designee

Paid
Preparer
Use Only

No

Designee’s
Phone
Personal identification
▶
▶
name
no. ▶
number (PIN)
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.
Your
signature

Date

▲

Sign
Here

Internal Use Only
DRAFT AS OF
March 7, 2013

Daytime phone number

Print/Type preparer’s name

Firm’s name

Capacity in which acting ▶

Preparer’s signature

Date

Check
if
self-employed

PTIN

Firm's EIN ▶

▶

Firm’s address ▶

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

▶

Phone no.
Cat. No. 11384V

Form 1042 (2014)

Version B, Cycle 9
Page 2

Form 1042 (2014)

63
a
b

c
d
e
64
a
b
c
d
e
65
66
67
a
b
68
69
70
71

Total tax reported as withheld or assumed on all Forms 1042-S and 1000:
Taxes withheld by withholding agent . . . . . . . . . . . . . . . . . . .
Taxes withheld by other withholding agents:
(1) For payments other than substitute dividends . . . . . . . . . . . . . . .
(2) For substitute dividends . . . . . . . . . . . . . . . . . . . . . .
Reimbursements . . . . . . . . . . . . . . . . . . . . . . . . .
Tax assumed by withholding agent . . . . . . . . . . . . . . . . . . .
Total tax reported as withheld or assumed (Add lines 63a-d) . . . . . . . . . .
Total net tax liability
Adjustments of underwithheld tax on corporate distributions made during the calendar year
Total net tax liability under chapter 3 . . . . . . . . . . . . . . . . . . .
Total net tax liability under chapter 4 . . . . . . . . . . . . . . . . . . .
Excise tax on specified federal procurement payments (Total payments made x 2%) . . .
Total net tax liability (Add lines 64 a-d) . . . . . . . . . . . . . . . . . .
Total paid by electronic funds transfer (or with a request for extension of time to file) . . .
Enter overpayment applied as credit from 2013 Form 1042 . . . . . . . . . . .
Credit for amounts withheld by other withholding agents:
For payments other than substitute dividend payments . . . . . . . . . . . . .
For substitute dividend payments . . . . . . . . . . . . . . . . . . . .
Total payments. Add lines 65 through 67 . . . . . . . . . . . . . . . . .
If line 64e is larger than line 68, enter balance due here . . . . . . . . . . . . .
If line 68 is larger than line 64e, enter overpayment here . . . . . . . . . . . .
Apply overpayment on line 70 to (check one):
Credit on 2015 Form 1042
or
Refund

Section 2
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63b(1)
63b(2)
63c (
63d
63e

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64a
64b
64c
64d
64e
65
66

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67a
67b
68
69
70

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2a
2b
2c
2d
2e
3
4
5

)

Internal Use Only
DRAFT AS OF
March 7, 2013

Reconciliation of Payments of U.S. Source FDAP Income

Total U.S. source FDAP income required to be withheld upon under chapter 4 . . . . . . .
Total U.S. source FDAP income not required to be withheld upon under chapter 4 because:
a Amount of income paid to recipients whose chapter 4 status established no withholding is required
b Amount of excluded nonfinancial payments (see instructions) . . . . . . . . . . . . .
c Amount of income paid with respect to grandfathered obligations . . . . . . . . . . .
d Amount of income effectively connected with the conduct of a trade or business in the U.S. . .
e Total U.S. source FDAP income not required to be withheld upon under chapter 4 (Add lines 2a-d)
3
Total U.S. source FDAP income reportable under chapter 4 (Add lines 1 and 2e) . . . . . .
4
Total U.S. source FDAP income reported on all Forms 1042-S (from line 62a, (b)(1), and (b)(2)) . .
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Total variance, subtract line 3 from line 4, if amount other than 0 provide explanation on line 6 . .
6

Section 3

63a

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Notional principal contract payments and other payments on derivative contracts that reference (in
whole or in part) a U.S. security

Check here if any payments (including gross proceeds) were made by the withholding agent under notional principal contracts
or other derivatives contracts that reference (in whole or in part) a U.S. security (see instructions) . . . . . . . . . .
Form 1042 (2014)