Form 1042-S Foreign Persons U.S. Source Income Subject to Withholdin

Version B, Cycle 17
Image area: 7.3" x 4.75"
Form

1042-S

Foreign Person’s U.S. Source Income Subject to Withholding
▶

Department of the Treasury
Internal Revenue Service
1 Income 2 Gross income
code

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

AMENDED

2014

PRO-RATA BASIS REPORTING

3 Chap. 3:

4 Chap. 4:

5 Withholding allowance

3a Exemption code

4a Exemption code

6 Net income

3b Tax rate

4b Tax rate

7 Federal tax withheld

OMB No. 1545-0096

Copy A for
Internal Revenue Service
Check if tax not deposited
under escrow procedure

Internal Use Only
DRAFT AS OF
May 8, 2013

8 Tax withheld by other agents
10 Total withholding credit
12 Withholding agent’s EIN

9 Tax assumed by withholding agent

Ch. 3 status code

Ch. 4 status code

11 Amount repaid to recipient
15 Intermediary or flow-through entity's EIN, if any Ch. 3 status code Ch. 4 status code

13a Withholding agent's name

16a Intermediary or flow-through entity's name

13b Withholding agent's Global Intermediary Identification Number (GIIN)
13c Country code
13d Foreign taxpayer identification number, if any

16b Intermediary or flow-through entity's GIIN
16c Country code
16d Foreign tax identification number, if any

13e Address (number and street)

16e Address (number and street)

13f City or town 13g State/Province 13h Country 13i ZIP or foreign postal code

16f City or town 16g State/Province 16h Country 16i ZIP or foreign postal code

14a RECIPIENT’S name

17 Recipient country code 18 Recipient's foreign taxpayer identification number, if any

14b Recipient's U.S. TIN, if any

14c Address (number and street)

Ch. 3 status code

Ch. 4 status code

19 Recipient account number

20 Recipient's date of birth

21 Payer's name

22 Payer's TIN

14d City or town 14e State/Province 14f Country 14g ZIP or foreign postal code 23 State income tax withheld

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

24 Payer’s state tax no.

Cat. No. 11386R

25 Name of state
Form 1042-S (2014)

Version B, Cycle 17
Image area: 7.3" x 4.75"
Form

1042-S

Foreign Person’s U.S. Source Income Subject to Withholding
▶

Department of the Treasury
Internal Revenue Service
1 Income 2 Gross income
code

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

AMENDED

2014

OMB No. 1545-0096

Copy B

PRO-RATA BASIS REPORTING

3 Chap. 3:

4 Chap. 4:

5 Withholding allowance

3a Exemption code

4a Exemption code

6 Net income

3b Tax rate

4b Tax rate

7 Federal tax withheld

for Recipient
Check if tax not deposited
under escrow procedure

Internal Use Only
DRAFT AS OF
May 8, 2013

8 Tax withheld by other agents
10 Total withholding credit
12 Withholding agent’s EIN

9 Tax assumed by withholding agent

Ch. 3 status code

Ch. 4 status code

11 Amount repaid to recipient
15 Intermediary or flow-through entity's EIN, if any Ch. 3 status code Ch. 4 status code

13a Withholding agent's name

16a Intermediary or flow-through entity's name

13b Withholding agent's Global Intermediary Identification Number (GIIN)
13c Country code
13d Foreign taxpayer identification number, if any

16b Intermediary or flow-through entity's GIIN
16c Country code
16d Foreign tax identification number, if any

13e Address (number and street)

16e Address (number and street)

13f City or town 13g State/Province 13h Country 13i ZIP or foreign postal code 16f City or town 16g State/Province 16h Country 16i ZIP or foreign postal code
14a RECIPIENT’S name

14b Recipient's U.S. TIN, if any

14c Address (number and street)

17 Recipient country code 18 Recipient's foreign taxpayer identification number, if any

Ch. 3 status code

Ch. 4 status code

19 Recipient account number

20 Recipient's date of birth

21 Payer's name

22 Payer's TIN

14d City or town 14e State/Province 14f Country 14g ZIP or foreign postal code 23 State income tax withheld

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

24 Payer’s state tax no.

Cat. No. 11386R

25 Name of state
Form 1042-S (2014)

Version B, Cycle 17
Image area: 7.3" x 4.75"

U.S. Income Tax Filing Requirements
Generally, every nonresident alien individual, nonresident alien
fiduciary, and foreign corporation with United States income, including
income that is effectively connected with the conduct of a trade or
business in the United States, must file a United States income tax
return. However, no return is required to be filed by a nonresident
alien individual, nonresident alien fiduciary, or foreign corporation if
such person was not engaged in a trade or business in the United
States at any time during the tax year and if the tax liability of such
person was fully satisfied by the withholding of United States tax at
the source. Corporations file Form 1120-F; all others file Form 1040NR
(or Form 1040NR-EZ if eligible). You may get the return forms and
instructions at any United States Embassy or consulate or by writing
to: Internal Revenue Service, 1201 N. Mitsubishi Motorway,
Bloomington, IL 61705-6613.

Por regla general, todo extranjero no residente, todo organismo
fideicomisario extranjero no residente y toda sociedad anónima
extranjera que reciba ingresos en los Estados Unidos, incluyendo
ingresos relacionados con la conducción de un negocio o comercio
dentro de los Estados Unidos, deberá presentar una declaración
estadounidense de impuestos sobre el ingreso. Sin embargo, no se
requiere declaración alguna a un individuo extranjero, una sociedad
anónima extranjera u organismo fideicomisario extranjero no
residente, si tal persona no ha efectuado comercio o negocio en los
Estados Unidos durante el año fiscal y si la responsabilidad con los
impuestos de tal persona ha sido satisfecha plenamente mediante
retención del impuesto de los Estados Unidos en la fuente. Las
sociedades anónimas envían el Formulario 1120-F; todos los demás
contribuyentes envían el Formulario 1040NR (o el Formulario 1040NREZ si les corresponde). Se podrá obtener formularios e instrucciones
en cualquier Embajada o Consulado de los Estados Unidos o
escribiendo directamente a: Internal Revenue Service, 1201 N.
Mitsubishi Motorway, Bloomington, IL 61705-6613.

Internal Use Only
DRAFT AS OF
May 8, 2013

En règle générale, tout étranger non-résident, tout organisme
fidéicommissaire étranger non-résident et toute société étrangère
percevant un revenu aux Etats-Unis, y compris tout revenu dérivé, en
fait, du fonctionnement d’un commerce ou d’une affaire aux EtatsUnis, doit produire une déclaration d’impôt sur le revenu auprès des
services fiscaux des Etats-Unis. Cependant aucune déclaration
d’impôt sur le revenu n’est exigée d’un étranger non-résident, d’un
organisme fidéicommissaire étranger non-résident, ou d’une société
étrangère s’ils n’ont pris part à aucun commerce ou affaire aux EtatsUnis à aucun moment pendant l’année fiscale et si les impôts dont ils
sont redevables, ont été entièrement acquittés par une retenue à la
source sur leur salaire. Les sociétés doivent faire leur déclaration
d’impôt en remplissant le formulaire 1120-F; tous les autres
redevables doivent remplir le formulaire 1040NR (ou 1040NR-EZ s'ils
en remplissent les conditions). On peut se procurer les formulaires de
déclarations d’impôts et les instructions y afférentes dans toutes les
Ambassades et tous les Consulats des Etats-Unis. L’on peut
également s’adresser pour tout renseignement à: Internal Revenue
Service, 1201 N. Mitsubishi Motorway, Bloomington, IL 61705-6613.

Im allgemeinen muss jede ausländische Einzelperson, jeder
ausländische Bevollmächtigte und jede ausländische Gesellschaft mit
Einkommen in den Vereinigten Staaten, einschliesslich des
Einkommens, welches direkt mit der Ausübung von Handel oder
Gewerbe innerhalb der Staaten verbunden ist, eine
Einkommensteuererklärung der Vereinigten Staaten abgeben. Eine
Erklärung, muss jedoch nicht von Ausländern, ausländischen
Bevollmächtigten oder ausländischen Gesellschaften in den
Vereinigten Staaten eingereicht werden, falls eine solche Person
während des Steuerjahres kein Gewerbe oder Handel in den
Vereinigten Staaten ausgeübt hat und die Steuerschuld durch
Einbehaltung der Steuern der Vereinigten Staaten durch die
Einkommensquelle abgegolten ist. Gesellschaften reichen den
Vordruck 1120-F ein; alle anderen reichen das Formblatt 1040NR
(oder wenn passend das Formblatt 1040NR-EZ) ein.
Einkommensteuererklärungen und Instruktionen können bei den
Botschaften und Konsulaten der Vereiningten Staaten eingeholt
werden. Um weitere Informationen wende man sich bitte an: Internal
Revenue Service, 1201 N. Mitsubishi Motorway, Bloomington, IL
61705-6613.

Version B, Cycle 17
Image area: 7.3" x 4.75"
Form

1042-S

Foreign Person’s U.S. Source Income Subject to Withholding
▶

Department of the Treasury
Internal Revenue Service
1 Income 2 Gross income
code

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

AMENDED

2014

PRO-RATA BASIS REPORTING

3 Chap. 3:

4 Chap. 4:

5 Withholding allowance

3a Exemption code

4a Exemption code

6 Net income

3b Tax rate

4b Tax rate

7 Federal tax withheld

OMB No. 1545-0096

Copy C for Recipient
Attach to any Federal tax return you file
Check if tax not deposited
under escrow procedure

Internal Use Only
DRAFT AS OF
May 8, 2013

8 Tax withheld by other agents
10 Total withholding credit
12 Withholding agent’s EIN

9 Tax assumed by withholding agent

Ch. 3 status code

Ch. 4 status code

11 Amount repaid to recipient
15 Intermediary or flow-through entity's EIN, if any Ch. 3 status code Ch. 4 status code

13a Withholding agent's name

16a Intermediary or flow-through entity's name

13b Withholding agent's Global Intermediary Identification Number (GIIN)
13c Country code
13d Foreign taxpayer identification number, if any

16b Intermediary or flow-through entity's GIIN
16c Country code
16d Foreign tax identification number, if any

13e Address (number and street)

16e Address (number and street)

13f City or town 13g State/Province 13h Country 13i ZIP or foreign postal code

16f City or town 16g State/Province 16h Country 16i ZIP or foreign postal code

14a RECIPIENT’S name

17 Recipient country code 18 Recipient's foreign taxpayer identification number, if any

14b Recipient's U.S. TIN, if any

14c Address (number and street)

Ch. 3 status code

Ch. 4 status code

19 Recipient account number

20 Recipient's date of birth

21 Payer's name

22 Payer's TIN

14d City or town 14e State/Province 14f Country 14g ZIP or foreign postal code 23 State income tax withheld

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

24 Payer’s state tax no.

Cat. No. 11386R

25 Name of state
Form 1042-S (2014)

Version B, Cycle 17
Image area: 7.3" x 4.75"

Explanation of Codes
Box 1. Income code.
01

Interest paid by U.S. obligors—general

02

Interest paid on real property mortgages

03

Interest paid to controlling foreign corporations

04

Interest paid by foreign corporations

05

Interest on tax-free covenant bonds

22

Interest paid on deposit with a foreign branch of a domestic corporation or partnership

29

Deposit interest

30
31

Other

Dividend

33

1 If

Types of Income

15

Scholarship or fellowship grants

16

Compensation for independent personal services1

17

Compensation for dependent personal services1

18

Compensation for teaching1

19

Compensation during studying and training1

Internal Use Only
DRAFT AS OF
May 8, 2013
20

Gross income—Other

24

Real estate investment trust (REIT) distributions of capital gains

25
26

Trust distributions subject to IRC section 1445

Original issue discount (OID)

27

Publicly traded partnership distributions subject to IRC section 1446

Short-term OID

28

Gambling winnings2

32

Notional principal contract income3

35

Substitute payment—other

36

Capital gains distributions

Substitute payment—interest

06

Dividends paid by U.S. corporations—general

07

Dividends qualifying for direct dividend rate

08

Dividends paid by foreign corporations

21

Gross income—Capital gain dividend

34

Substitute payment—dividends

40

Other dividend equivalents under IRC section 871(m) (formerly 871(l))

09

Other

Interest

Code

Unsevered growing crops and timber distributions by a trust subject
to IRC section 1445

37

Return of capital

38

Eligible deferred compensation items subject to IRC section 877A(d)(1)

39

Distributions from a nongrantor trust subject to IRC section 877A(f)(1)

41

Guarantee of indebtedness

42

Earnings as an artist or athlete—no central withholding agreement4

Capital gains

43

Earnings as an artist or athlete—central withholding agreement4

10

Industrial royalties

44

Transportation and freight income

11

Motion picture or television copyright royalties

50

Income previously reported under escrow procedure5

12

Other royalties (for example, copyright, recording, publishing)

51

Other income

13

Real property income and natural resources royalties

14

Pensions, annuities, alimony, and/or insurance premiums

See back of Copy D for additional codes

compensation that otherwise would be covered under Income Codes 16 through 19 is directly attributable to the recipient’s occupation as an artist or athlete, use Income Code 42 or 43 instead.

2 Subject

to 30% withholding rate unless the recipient is from one of the treaty countries listed under Gambling winnings (Income Code 28) in Pub. 515.

3 Use

appropriate Interest Income Code for embedded interest in a notional principal contract.
4 If Income Code 42 or 43 is used, Recipient Code 09 (artist or athlete) should be used instead of Recipient Code 01 (individual), 02 (corporation), or 03 (partnership other than withholding foreign
partnership).
5 Use

only to report gross income the tax for which is being deposited in the current year because such tax was previously escrowed for chapters 3 and 4 and the withholding agent previously
reported the gross income in a prior year and checked the box to report the tax as not deposited under the escrow procedure.

Version B, Cycle 17
Image area: 7.3" x 4.75"
Form

1042-S

Foreign Person’s U.S. Source Income Subject to Withholding
▶

Department of the Treasury
Internal Revenue Service
1 Income 2 Gross income
code

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

AMENDED

2014

PRO-RATA BASIS REPORTING

3 Chap. 3:

4 Chap. 4:

5 Withholding allowance

3a Exemption code

4a Exemption code

6 Net income

3b Tax rate

4b Tax rate

7 Federal tax withheld

OMB No. 1545-0096

Copy D for Recipient
Attach to any state tax return you file
Check if tax not deposited
under escrow procedure

Internal Use Only
DRAFT AS OF
May 8, 2013

8 Tax withheld by other agents
10 Total withholding credit
12 Withholding agent’s EIN

9 Tax assumed by withholding agent

Ch. 3 status code

Ch. 4 status code

11 Amount repaid to recipient
15 Intermediary or flow-through entity's EIN, if any Ch. 3 status code Ch. 4 status code

13a Withholding agent's name

16a Intermediary or flow-through entity's name

13b Withholding agent's Global Intermediary Identification Number (GIIN)
13c Country code
13d Foreign taxpayer identification number, if any

16b Intermediary or flow-through entity's GIIN
16c Country code
16d Foreign tax identification number, if any

13e Address (number and street)

16e Address (number and street)

13f City or town 13g State/Province 13h Country 13i ZIP or foreign postal code 16f City or town 16g State/Province 16h Country 16i ZIP or foreign postal code
14a RECIPIENT’S name

14b Recipient's U.S. TIN, if any

14c Address (number and street)

17 Recipient country code 18 Recipient's foreign taxpayer identification number, if any

Ch. 3 status code

Ch. 4 status code

19 Recipient account number

20 Recipient's date of birth

21 Payer's name

22 Payer's TIN

14d City or town 14e State/Province 14f Country 14g ZIP or foreign postal code 23 State income tax withheld

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

24 Payer’s state tax no.

Cat. No. 11386R

25 Name of state
Form 1042-S (2014)

Version B, Cycle 17
Image area: 7.3" x 4.75"

Explanation of Codes (continued)
Boxes 3a and 4a. Exemption code (applies if the tax rate entered in boxes 3a and
4a is 00.00).
Code

Authority for Exemption

Chapter 3
01 Effectively connected income
02 Exempt under IRC (other than portfolio interest)
04 Exempt under tax treaty

05 Portfolio interest exempt under IRC

06 QI that assumes primary withholding responsibility
08 U.S. branch treated as U.S. Person

09 Territory FI treated as U.S. Person
10 QI represents that income is exempt
11 QSL that assumes primary withholding responsibility
12

Payee subjected to chapter 4 withholding

Chapter 4

15 Payee not subject to chapter 4 withholding
16 Excluded nonfinancial payment
17 Foreign reportable amounts

18 Foreign Entity that assumes primary withholding responsibility
19 U.S. Payees—of participating FFI or registered deemed-compliant FFI
20 Recalcitrant account holders exempt from withholding under IGA
21 Dormant account1
Type of Recipient, Withholding Agent, or Intermediary

Chapter 3 Status Codes
01 U.S. Withholding Agent—FI
02 U.S. Withholding Agent—Other
03 Territory FI treated as U.S. Person
1 Use

06 U.S. branch of Participating FFI—not treated as U.S. Person
07 U.S. branch of Registered Deemed-Compliant FFI—treated as U.S. Person
08 Partnership other than Withholding Foreign Partnership
09 Withholding Foreign Partnership

10 Trust other than Withholding Foreign Trust
11 Withholding Foreign Trust
12 Qualified Intermediary

13 Qualified Intermediary—Branch under Qualified Intermediary Agreement
14 Qualified Intermediary—Branch not under Qualified Intermediary Agreement
15 Qualified Intermediary—Foreign Branch of U.S. FI

16 Qualified Securities Lender—Qualified Intermediary
17 Qualified Securities Lender—Other
18 Corporation
19 Individual

13 Grandfathered payment
14 Effectively connected income

Code

05 U.S. branch of Participating FFI—treated as U.S. Person

Internal Use Only
DRAFT AS OF
May 8, 2013

03 Income is not from U.S. sources

07 WFP or WFT

04 Territory FI—not treated as U.S. Person

20 Estate

21 Private Foundation

22 International Organization

23 Tax Exempt Organization (Section 501(c) entities)
24 Unknown Recipient
25 Artist or Athlete
26 Pension
27 Foreign Government—Integral Part
28 Foreign Government—Controlled Entity
29 Government of U.S. territory
30 Foreign Central Bank of Issue

Pooled Reporting Codes
31 Withholding Rate Pool—General
32 Withholding Rate Pool—Exempt Organization

only when tax not withheld under chapter 4 because escrow procedure for dormant accounts applied under chapter 4 but tax withheld under chapter 3.

Version B, Cycle 17
Image area: 7.3" x 4.75"

Explanation of Codes (continued)
Code

Type of Recipient, Withholding Agent, or Intermediary

Chapter 4 Status Codes

24 Active NFFE
25 Excepted NFFE—Other

01 U.S. Withholding Agent—FI
02 U.S. Withholding Agent—Other

26 Individual

03 Territory FI—not treated as U.S. Person

28 Excepted Territory NFFE

27 Section 501(c) Entities

Internal Use Only
DRAFT AS OF
May 8, 2013

04 Territory FI—treated as U.S. Person

29 Exempt Beneficial Owner

05 U.S. branch of Participating FFI—treated as U.S. Person

30 Entity Wholly Owned By Exempt Beneficial Owners

06 U.S. branch of Participating FFI—not treated as U.S. Person

31 Unknown Recipient

07 U.S. branch of Registered Deemed-Compliant FFI—treated as U.S. Person

32 Recalcitrant Account Holder

08 Participating FFI—Other

33 NFFE—WP or WT

09 Participating FFI—Reporting Model 2 FFI

10 Registered Deemed-Compliant FFI—Reporting Model 1 FFI
11 Registered Deemed-Compliant FFI—Sponsored Entity

34 Nonreporting IGA FFI

Pooled Reporting Codes
35 Recalcitrant Pool—No U.S. Indicia

12 Registered Deemed-Compliant FFI—Other

36 Recalcitrant Pool—U.S. Indicia

13 Certified Deemed-Compliant FFI—Other
14 Certified Deemed-Compliant FFI—FFI with Low Value Accounts

37 Recalcitrant Pool—Dormant Account

15 Certified Deemed-Compliant FFI—Non-Registering Local Bank

39 Recalcitrant Pool—Passive NFFEs

16 Certified Deemed-Compliant FFI—Sponsored Entity
17 Nonparticipating FFI

40 Nonparticipating FFI Pool

18 Owner-Documented FFI
19 Limited Branch treated as Nonparticipating FFI

42 U.S. Payees Pool

20 Limited FFI treated as Nonparticipating FFI
21 Passive NFFE identifying Substantial U.S. Owners
22 Passive NFFE with no Substantial U.S. Owners
23 Publicly Traded Corporation or Affiliate of Publicly Traded Corporation

38 Recalcitrant Pool—U.S. Persons

41 QI—Exempt from Chapter 4 Withholding Pool

Version B, Cycle 17
Image area: 7.3" x 4.75"
Form

1042-S

Foreign Person’s U.S. Source Income Subject to Withholding
▶

Department of the Treasury
Internal Revenue Service
1 Income 2 Gross income
code

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

AMENDED

2014

PRO-RATA BASIS REPORTING

3 Chap. 3:

4 Chap. 4:

5 Withholding allowance

3a Exemption code

4a Exemption code

6 Net income

3b Tax rate

4b Tax rate

7 Federal tax withheld

OMB No. 1545-0096

Copy E

for Withholding Agent
Check if tax not deposited
under escrow procedure

Internal Use Only
DRAFT AS OF
May 8, 2013

8 Tax withheld by other agents
10 Total withholding credit
12 Withholding agent’s EIN

9 Tax assumed by withholding agent

Ch. 3 status code

Ch. 4 status code

11 Amount repaid to recipient
15 Intermediary or flow-through entity's EIN, if any Ch. 3 status code Ch. 4 status code

13a Withholding agent's name

16a Intermediary or flow-through entity's name

13b Withholding agent's Global Intermediary Identification Number (GIIN)
13c Country code
13d Foreign taxpayer identification number, if any

16b Intermediary or flow-through entity's GIIN
16c Country code
16d Foreign tax identification number, if any

13e Address (number and street)

16e Address (number and street)

13f City or town 13g State/Province 13h Country 13i ZIP or foreign postal code 16f City or town 16g State/Province 16h Country 16i ZIP or foreign postal code
14a RECIPIENT’S name

14b Recipient's U.S. TIN, if any

14c Address (number and street)

17 Recipient country code 18 Recipient's foreign taxpayer identification number, if any

Ch. 3 status code

Ch. 4 status code

19 Recipient account number

20 Recipient's date of birth

21 Payer's name

22 Payer's TIN

14d City or town 14e State/Province 14f Country 14g ZIP or foreign postal code 23 State income tax withheld

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

24 Payer’s state tax no.

Cat. No. 11386R

25 Name of state
Form 1042-S (2014)