1042-S Foreign Person’s U.S. Source Income Subject to Withholdi

Version A, Cycle 7
Image area: 7.3" x 4.75"
Form

1042-S

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

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

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

AMENDED

2015

OMB No. 1545-0096

Copy A for
Internal Revenue Service

PRO-RATA BASIS REPORTING

3 Chap. 3:

4 Chap. 4:

5 Withholding allowance

3a Exemption code

4a Exemption code

6 Net income

Check if tax not deposited with IRS

3b Tax rate

4b Tax rate

7 Federal tax withheld

pursuant to escrow procedure

INTERNAL USE ONLY
DRAFT AS OF
October 31, 2014

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

9 Tax paid by withholding agent

11 Amount repaid to recipient
12b Ch. 3 status code 12c Ch. 4 status code 14a Primary Withholding Agent's Name (if applicable)
14b Primary Withholding Agent's EIN

15a Intermediary or flow-through entity's EIN, if any

12d Withholding agent's name

15b Ch. 3 status code 15c Ch. 4 status code

12e Withholding agent's Global Intermediary Identification Number (GIIN)

15d Intermediary or flow-through entity's name

12f Country code

12g Foreign taxpayer identification number, if any

15e Intermediary or flow-through entity's GIIN
15f Country code
15g Foreign tax identification number, if any

12h Address (number and street)

15h Address (number and street)

12i City or town, state or province, country, ZIP or foreign postal code

15i City or town, state or province, country, ZIP or foreign postal code

13a Recipient's U.S. TIN, if any

13h Recipient's GIIN

13b Ch. 3 status code
13d Recipient's name

13i Recipient's foreign tax identification number, if any

13c Ch. 4 status code
13e Recipient's country code

16 Recipient's account number

17 Recipient's date of birth

13f Address (number and street)

18 Payer's name

19 Payer's TIN

13g City or town, state or province, country, ZIP or foreign postal code

21 State income tax withheld

22 Payer’s state tax no.

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

Cat. No. 11386R

20 Payer's GIIN
23 Name of state
Form 1042-S (2015)

Version A, Cycle 7
Image area: 7.3" x 4.75"
Form

1042-S

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

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

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

AMENDED

2015

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 with IRS
pursuant to escrow procedure

INTERNAL USE ONLY
DRAFT AS OF
October 31, 2014

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

9 Tax paid by withholding agent

11 Amount repaid to recipient
12b Ch. 3 status code 12c Ch. 4 status code 14a Primary Withholding Agent's Name (if applicable)
14b Primary Withholding Agent's EIN

15a Intermediary or flow-through entity's EIN, if any

12d Withholding agent's name

15b Ch. 3 status code 15c Ch. 4 status code

12e Withholding agent's Global Intermediary Identification Number (GIIN)

15d Intermediary or flow-through entity's name

12f Country code

12g Foreign taxpayer identification number, if any

15e Intermediary or flow-through entity's GIIN
15f Country code
15g Foreign tax identification number, if any

12h Address (number and street)

15h Address (number and street)

12i City or town, state or province, country, ZIP or foreign postal code

15i City or town, state or province, country, ZIP or foreign postal code

13a Recipient's U.S. TIN, if any

13h Recipient's GIIN

13b Ch. 3 status code
13d Recipient's name

13i Recipient's foreign tax identification number, if any

13c Ch. 4 status code
13e Recipient's country code

16 Recipient's account number

17 Recipient's date of birth

13f Address (number and street)

18 Payer's name

19 Payer's TIN

13g City or town, state or province, country, ZIP or foreign postal code

21 State income tax withheld

22 Payer’s state tax no.

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

Cat. No. 11386R

20 Payer's GIIN
23 Name of state
Form 1042-S (2015)

Version A, Cycle 7
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 1040NR-EZ 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
October 31, 2014

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 Etats-Unis, 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 Etats-Unis 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.

01
02
03
04
05
22
29
30
31
33
51

Types of Income
Interest paid by U.S. obligors—general
Interest paid on real property mortgages
Interest paid to controlling foreign corporations
Interest paid by foreign corporations
Interest on tax-free covenant bonds
Interest paid on deposit with a foreign branch of a domestic corporation or partnership
Deposit Interest
Original issue discount (OID)
Short-term OID
Substitute payment—interest
Interest paid on certain actively traded or publicly offered securities1

Dividend

Interest

Box 1. Income code.
Code

06
07
08
21
34
40
52
53

Other

Explanation of Codes

09
10
11
12
13
14

Dividends paid by U.S. corporations—general
Dividends qualifying for direct dividend rate
Dividends paid by foreign corporations
Gross income—Capital gain dividend
Substitute payment—dividends
Other dividend equivalents under IRC section 871(m) (formerly 871(l))
Dividends paid on certain actively traded or publicly offered securities1
Substitute payments-dividends from certain actively traded or publicly
offered securities1
Capital gains
Industrial royalties
Motion picture or television copyright royalties
Other royalties (for example, copyright, recording, publishing)
Royalties paid on certain publicly offered securities1
Real property income and natural resources royalties

See back of Copy C for additional codes
code should only be used if the income paid is described in Regulations section 1.1441-6(c)(2) and withholding agent has reduced the rate of withholding under an income tax treaty without the
recipient providing a U.S. or foreign TIN.
1 This

Version A, Cycle 7
Image area: 7.3" x 4.75"
Form

1042-S

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

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

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

AMENDED

2015

OMB No. 1545-0096

Copy C for Recipient

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

Attach to any Federal tax return you file
Check if tax not deposited with IRS
pursuant to escrow procedure

INTERNAL USE ONLY
DRAFT AS OF
October 31, 2014

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

9 Tax paid by withholding agent

11 Amount repaid to recipient
12b Ch. 3 status code 12c Ch. 4 status code 14a Primary Withholding Agent's Name (if applicable)
14b Primary Withholding Agent's EIN

15a Intermediary or flow-through entity's EIN, if any

12d Withholding agent's name

15b Ch. 3 status code 15c Ch. 4 status code

12e Withholding agent's Global Intermediary Identification Number (GIIN)

15d Intermediary or flow-through entity's name

12f Country code

12g Foreign taxpayer identification number, if any

15e Intermediary or flow-through entity's GIIN
15f Country code
15g Foreign tax identification number, if any

12h Address (number and street)

15h Address (number and street)

12i City or town, state or province, country, ZIP or foreign postal code

15i City or town, state or province, country, ZIP or foreign postal code

13a Recipient's U.S. TIN, if any

13h Recipient's GIIN

13b Ch. 3 status code
13d Recipient's name

13i Recipient's foreign tax identification number, if any

13c Ch. 4 status code
13e Recipient's country code

16 Recipient's account number

17 Recipient's date of birth

13f Address (number and street)

18 Payer's name

19 Payer's TIN

13g City or town, state or province, country, ZIP or foreign postal code

21 State income tax withheld

22 Payer’s state tax no.

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

Cat. No. 11386R

20 Payer's GIIN
23 Name of state
Form 1042-S (2015)

Version A, Cycle 7
Image area: 7.3" x 4.75"

Explanation of Codes (continued)
15
16
17
18
19
20
23
24
25
26

Other

Pensions, annuities, alimony, and/or insurance premiums
Scholarship or fellowship grants
Compensation for independent personal services2
Compensation for dependent personal services2
Compensation for teaching2
Compensation during studying and training2
Gross income—Other
Real estate investment trust (REIT) distributions of capital gains
Trust distributions subject to IRC section 1445
Unsevered growing crops and timber distributions by a trust subject
to IRC section 1445
27
Publicly traded partnership distributions subject to IRC section 1446
28
Gambling winnings3
32
Notional principal contract income4
35
Substitute payment—other
36
Capital gains distributions
37
Return of capital
Eligible deferred compensation items subject to IRC section 877A(d)(1)
38
39
Distributions from a nongrantor trust subject to IRC section 877A(f)(1)
Guarantee of indebtedness
41
42
Earnings as an artist or athlete—no central withholding agreement5
43
Earnings as an artist or athlete—central withholding agreement5
44
Specified Federal procurement payments
50
Income previously reported under escrow procedure6
54
Other income
Boxes 3a and 4a. Exemption code (applies if the tax rate entered in boxes 3b and 4b is 00.00).
Code
Authority for Exemption
Chapter 3
Effectively connected income
01
02
Exempt under IRC (other than portfolio interest)
03
Income is not from U.S. sources
2 If

INTERNAL USE ONLY
DRAFT AS OF
October 31, 2014
See back of Copy D for additional codes

compensation that otherwise would be covered under Income Codes 17 through 20 is directly attributable to the recipient’s occupation as an artist or athlete, use Income Code 42 or 43 instead.

3 Subject
4 Use
5 If

04
Exempt under tax treaty
05
Portfolio interest exempt under IRC
06
QI that assumes primary withholding responsibility
07
WFP or WFT
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
13
Grandfathered payment
14
Effectively connected income
15
Payee not subject to chapter 4 withholding
16
Excluded nonfinancial payment
17
Foreign Entity that assumes primary withholding responsibility
U.S. Payees—of participating FFI or registered deemed-compliant FFI
18
19
Exempt from withholding under IGA7
20
Dormant account8
Excluded payment on offshore obligation
21
22
Excluded payments on Collateral9
Code
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
04
Territory FI—not treated as U.S. Person
05
U.S. branch—treated as U.S. Person
06
U.S. branch—not treated as U.S. Person
07
U.S. branch—EIC presumption applied
08
Partnership other than Withholding Foreign Partnership
09
Withholding Foreign Partnership

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

appropriate Interest Income Code for embedded interest in a notional principal contract.

Income Code 42 or 43 is used, Recipient Code 22 (artist or athlete) should be used instead of Recipient Code 16 (individual), 15 (corporation), or 08 (partnership other than withholding foreign partnership).

6 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. See the instructions to this form for further explanation.
7 Use only to report a U.S. reportable account or non-consenting U.S. account that is receiving a payment subject to chapter 3 withholding.
8 Use only if applying the escrow procedure for dormant accounts under Regulations section 1.1471-4(b)(6). If tax was withheld and deposited under chapter 3, do not check the “tax not deposited
with IRS pursuant to escrow procedure” box. You must instead check box 3 and complete box 3b.
9 This

code should only be used if the income paid is not subject to withholding under chapter 4 pursuant to Regulations section 1.1473-1(a)(4)(vii).

Version A, Cycle 7
Image area: 7.3" x 4.75"
Form

1042-S

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

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

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

AMENDED

2015

OMB No. 1545-0096

Copy D for Recipient

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

Attach to any state tax return you file
Check if tax not deposited with IRS
pursuant to escrow procedure

INTERNAL USE ONLY
DRAFT AS OF
October 31, 2014

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

9 Tax paid by withholding agent

11 Amount repaid to recipient
12b Ch. 3 status code 12c Ch. 4 status code 14a Primary Withholding Agent's Name (if applicable)
14b Primary Withholding Agent's EIN

15a Intermediary or flow-through entity's EIN, if any

12d Withholding agent's name

15b Ch. 3 status code 15c Ch. 4 status code

12e Withholding agent's Global Intermediary Identification Number (GIIN)

15d Intermediary or flow-through entity's name

12f Country code

12g Foreign taxpayer identification number, if any

15e Intermediary or flow-through entity's GIIN
15f Country code
15g Foreign tax identification number, if any

12h Address (number and street)

15h Address (number and street)

12i City or town, state or province, country, ZIP or foreign postal code

15i City or town, state or province, country, ZIP or foreign postal code

13a Recipient's U.S. TIN, if any

13h Recipient's GIIN

13b Ch. 3 status code
13d Recipient's name

13i Recipient's foreign tax identification number, if any

13c Ch. 4 status code
13e Recipient's country code

16 Recipient's account number

17 Recipient's date of birth

13f Address (number and street)

18 Payer's name

19 Payer's TIN

13g City or town, state or province, country, ZIP or foreign postal code

21 State income tax withheld

22 Payer’s state tax no.

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

Cat. No. 11386R

20 Payer's GIIN
23 Name of state
Form 1042-S (2015)

Version A, Cycle 7
Image area: 7.3" x 4.75"

Explanation of Codes (continued)

12
Certified Deemed-Compliant FFI—Non-Registering Local Bank
13
Certified Deemed-Compliant FFI—Sponsored Entity
10
Trust other than Withholding Foreign Trust
14
Certified Deemed-Compliant FFI—Investment Advisor or Investment Manager
11
Withholding Foreign Trust
15
Nonparticipating FFI
12
Qualified Intermediary
16
Owner-Documented FFI
Qualified Securities Lender—Qualified Intermediary
13
17
Limited Branch treated as Nonparticipating FFI
14
Qualified Securities Lender—Other
18
Limited FFI treated as Nonparticipating FFI
15
Corporation
19
Passive NFFE identifying Substantial U.S. Owners
16
Individual
20
Passive NFFE with no Substantial U.S. Owners
17
Estate
21
Publicly Traded NFFE or Affiliate of Publicly Traded NFFE
18
Private Foundation
22
Active NFFE
19
Government or International Organization
23
Individual
20
Tax Exempt Organization (Section 501(c) entities)
Section 501(c) Entities
24
21
Unknown Recipient
Excepted Territory NFFE
22
Artist or Athlete
25
23
Pension
Excepted NFFE — Other
26
Exempt Beneficial Owner
24
Foreign Central Bank of Issue
27
25
Nonqualified Intermediary
Entity Wholly Owned by Exempt Beneficial Owners
28
Unknown Recipient
26
Hybrid entity making Treaty Claim
29
Recalcitrant Account Holder
30
Pooled Reporting Codes10
Nonreporting IGA FFI
31
27
Withholding Rate Pool—General
Direct reporting NFFE
32
28
Withholding Rate Pool—Exempt Organization
U.S. reportable account
33
29
PAI Withholding Rate Pool—General
Non-consenting U.S. account
34
30
PAI Withholding Rate Pool—Exempt Organization
Sponsored direct reporting NFFE
35
31
Agency Withholding Rate Pool—General
Excepted Inter-affiliate FFI
36
32
Agency Withholding Rate Pool—Exempt Organization
Undocumented Preexisting Obligation
37
33
Joint account withholding rate pool
U.S. Branch—ECI presumption applied
38
Chapter 4 Status Codes
Account Holder of Excluded Financial Account11
39
01
U.S. Withholding Agent—FI
40
Passive NFFE reported by FFI12
02
U.S. Withholding Agent—Other
41
NFFE subject to 1472 withholding
03
Territory FI—not treated as U.S. Person
Pooled Reporting Codes
04
Territory FI—treated as U.S. Person
42
Recalcitrant Pool—No U.S. Indicia
05
Participating FFI—Other
43
Recalcitrant Pool—U.S. Indicia
06
Participating FFI—Reporting Model 2 FFI
44
Recalcitrant Pool—Dormant Account
07
Registered Deemed-Compliant FFI—Reporting Model 1 FFI
45
Recalcitrant Pool—U.S. Persons
08
Registered Deemed-Compliant FFI—Sponsored Entity
46
Recalcitrant Pool—Passive NFFEs
09
Registered Deemed-Compliant FFI—Other
47
Nonparticipating FFI Pool
10
Certified Deemed-Compliant FFI—Other
48
U.S. Payees Pool
11
49
Certified Deemed-Compliant FFI—FFI with Low Value Accounts
QI-Recalcitrant Pool—GeneraI13
10 These codes should only be used by a QI, QSL, WP, or WT.
11 This code should only be used if income is paid to an account that is excluded from the definition of financial account under Regulations section 1.1471-5(b)(2) or under Annex II of the applicable Model 1 IGA or Model 2 IGA.

INTERNAL USE ONLY
DRAFT AS OF
October 31, 2014

12 This

code should only be used when the withholding agent has received a certification on the FFI withholding statement of a participating FFI or registered deemed-compliant FFI that maintains the account that the FFI
has reported the account held by the passive NFFE as a U.S. account (or U.S. reportable account) under it's FATCA requirements. The withholding agent must report the name and GIIN of such FFA in box 15d and 15e.

13 This

code should only be used by a withholding agent that is reporting a payment (or portion of a payment) made to a QI with respect to the QI's recalcitrant account holders.

Version A, Cycle 7
Image area: 7.3" x 4.75"
Form

1042-S

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

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

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

AMENDED

2015

OMB No. 1545-0096

Copy E

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 Withholding Agent
Check if tax not deposited with IRS
pursuant to escrow procedure

INTERNAL USE ONLY
DRAFT AS OF
October 31, 2014

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

9 Tax paid by withholding agent

11 Amount repaid to recipient
12b Ch. 3 status code 12c Ch. 4 status code 14a Primary Withholding Agent's Name (if applicable)
14b Primary Withholding Agent's EIN

15a Intermediary or flow-through entity's EIN, if any

12d Withholding agent's name

15b Ch. 3 status code 15c Ch. 4 status code

12e Withholding agent's Global Intermediary Identification Number (GIIN)

15d Intermediary or flow-through entity's name

12f Country code

12g Foreign taxpayer identification number, if any

15e Intermediary or flow-through entity's GIIN
15f Country code
15g Foreign tax identification number, if any

12h Address (number and street)

15h Address (number and street)

12i City or town, state or province, country, ZIP or foreign postal code

15i City or town, state or province, country, ZIP or foreign postal code

13a Recipient's U.S. TIN, if any

13h Recipient's GIIN

13b Ch. 3 status code
13d Recipient's name

13i Recipient's foreign tax identification number, if any

13c Ch. 4 status code
13e Recipient's country code

16 Recipient's account number

17 Recipient's date of birth

13f Address (number and street)

18 Payer's name

19 Payer's TIN

13g City or town, state or province, country, ZIP or foreign postal code

21 State income tax withheld

22 Payer’s state tax no.

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

Cat. No. 11386R

20 Payer's GIIN
23 Name of state
Form 1042-S (2015)