Form 8966-C Cover Sheet for Form 8966 Paper Submssions

8966-C

XXXX

Cover Sheet for Form 8966 Paper Submissions

DO NOT STAPLE
Form

1042-T

OMB No. 1545-0096

Annual Summary and Transmittal of
Forms 1042-S
filer

Department of the Treasury
Internal Revenue Service

2014

Employer
1) Ch. 4 Status
CodeNumber
Global Intermediary
Identification
(GIIN)identification number

Name of withholding agent

2) Ch. 3 Status Code
□□□□□□.□□.□□□

Number, street, and room or suite no.

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

8966

1a
1

Type of paper Forms 1042-S attached (check only one box):
Also check here if pro-rata (see instructions) a
2b Number of paper Forms 1042-S attached a

2

Original

Total gross income reported on all paper Forms 1042-S (box 2) attached .

3
Total federal tax withheld on all paper Forms 1042-S attached:
a Total federal tax withheld under chapter 4 . . . . . . . .
b Total federal tax withheld under chapter 3 . . . . . . . .

.
.

.
.

.
.

Amended

.

.

.

.

.

Corrected

.

.

.

Voided

$

$
$

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)

Insert A from
next page

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
F

Sign
Here

a

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).
Electronic filing requirement. If you file 250 or more Forms 1042S, you are required to submit them electronically. If you submit less
than 250 Forms 1042-S, you are encouraged to file them
electronically. If you are a financial institution you are required to
submit Form 1042-S electronically irrespective of the number of
Forms 1042-S you submit. If you submit Forms 1042-S
electronically, do not use Form 1042-T. See the instructions for
Form 1042 for the definition of financial institution.
Filing Forms 1042 and 1042-S. 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 2014, 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 2014 and an attached
Form 1042-S caused the gross income or tax withheld information
previously reported on line 62c or 63e 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 16, 2015.
Send the forms in a flat mailing (not folded).

Date

Daytime phone number

Identifying information at top of form. The name, address, EIN,
and chapter 4 and 3 status codes of the withholding agent named
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. See the instructions for Form 1042-S for the
withholding agent codes for the chapter 3 and 4 status codes. See
instructions for Form 1042-S for the definition of withholdable
payment to determine when a chapter 4 status code is required.
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 non pro-rata
• Original pro-rata
• Amended non pro-rata

• Amended pro-rata

Each type must be transmitted with a separate Form 1042-T. For
example, you must transmit only original non pro-rata Forms 1042S with one Form 1042-T.
Line 2. Enter the total of the gross income amounts shown on the
Forms 1042-S (box 2) being transmitted with this Form 1042-T.
Line 3. Enter the total of the federal tax withheld amounts shown on
all Forms 1042-S (total of boxes 7, 8, and 9) being transmitted with
this Form 1042-T. Allocate withheld amounts between chapter 4
and chapter 3 on lines 3a and 3b.
Final return. If you will not be required to file additional Forms
1042-S, including amended Forms 1042-S for the 2014 year (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 (2014)

8966.
67369U

8966-C

(2015)

15

Insert A

Please ensure only one box is checked on line 1. If this transmittal is
submitting corrected, amended, or voided reports, please ensure all
attached Forms 8966 submitted under this cover sheet are correctly
marked and consistent with the box checked on line 1.