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

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/form1042s.

AMENDED

3b Tax rate

4a Exemption code
.

4b Tax rate

.

13f Ch. 3 status code
13h Recipient's GIIN

13g Ch. 4 status code
13i Recipient's foreign tax identification

13k Recipient's account number

8 Tax withheld by other agents

13j LOB code

number, if any

7b Check if tax not deposited with
IRS pursuant to escrow procedure

7a Federal tax withheld

Copy A for
Internal Revenue Service

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

5 Withholding allowance
6 Net income

OMB No. 1545-0096

PRO-RATA BASIS REPORTING

3 Chapter indicator. Enter “3” or “4”
3a Exemption code

2016

13l Recipient's date of birth

9 Tax paid by withholding agent
14a Primary Withholding Agent's Name (if applicable)

10 Total withholding credit
11 Amount repaid to recipient
12a Withholding agent’s EIN

14b Primary Withholding Agent's EIN
12b Ch. 3 status code

12c Ch. 4 status code

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

12d Withholding agent's name

15d Intermediary or flow-through entity's name

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

15e Intermediary or flow-through entity's GIIN
15f Country code

12f Country code

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

15g Foreign tax identification number, if any

12g Foreign taxpayer identification number, if any
15h Address (number and street)

12h Address (number and street)
15i City or town, state or province, country, ZIP or foreign postal code
12i City or town, state or province, country, ZIP or foreign postal code
16a Payer's name
13a Recipient's name

16b Payer's TIN

13b Recipient's country code
16c Payer's GIIN

16d Ch. 3 status
code

13c Address (number and street)
13d City or town, state or province, country, ZIP or foreign postal code

17a State income tax withheld

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

16e Ch. 4 status
code

17b Payer’s state tax no. 17c Name of state

Cat. No. 11386R

Form 1042-S (2016)

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/form1042s.

AMENDED

3b Tax rate

4a Exemption code
.

4b Tax rate

.

13f Ch. 3 status code
13h Recipient's GIIN

13g Ch. 4 status code
13i Recipient's foreign tax identification

13k Recipient's account number

8 Tax withheld by other agents

13j LOB code

number, if any

7b Check if tax not deposited with
IRS pursuant to escrow procedure

7a Federal tax withheld

Copy B

for Recipient

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

5 Withholding allowance
6 Net income

OMB No. 1545-0096

PRO-RATA BASIS REPORTING

3 Chapter indicator. Enter “3” or “4”
3a Exemption code

2016

13l Recipient's date of birth

9 Tax paid by withholding agent
14a Primary Withholding Agent's Name (if applicable)

10 Total withholding credit
11 Amount repaid to recipient
12a Withholding agent’s EIN

14b Primary Withholding Agent's EIN
12b Ch. 3 status code

12c Ch. 4 status code

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

12d Withholding agent's name

15d Intermediary or flow-through entity's name

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

15e Intermediary or flow-through entity's GIIN
15f Country code

12f Country code

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

15g Foreign tax identification number, if any

12g Foreign taxpayer identification number, if any
15h Address (number and street)

12h Address (number and street)
15i City or town, state or province, country, ZIP or foreign postal code
12i City or town, state or province, country, ZIP or foreign postal code
16a Payer's name
13a Recipient's name

16c Payer's GIIN
13c Address (number and street)
13d City or town, state or province, country, ZIP or foreign postal code

(keep for your records)

16b Payer's TIN

13b Recipient's country code

17a State income tax withheld

16d Ch. 3 status
code

16e Ch. 4 status
code

17b Payer’s state tax no. 17c Name of state
Form 1042-S (2016)

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.
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.

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.
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.

Explanation of Codes

03
04
05

Interest paid to controlling foreign corporations
Interest paid by foreign corporations
Interest on tax-free covenant bonds

22

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

29
30
31
33

Deposit Interest
Original issue discount (OID)
Short-term OID
Substitute payment—interest
Interest paid on certain actively traded or publicly offered
securities1

Dividend

51
06

Dividends paid by U.S. corporations—general

07
08
34

Dividends qualifying for direct dividend rate
Dividends paid by foreign corporations
Substitute payment—dividends

Other

Interest

Types of Income
Code
01
Interest paid by U.S. obligors—general
02
Interest paid on real property mortgages

Dividend

Box 1. Income code.

40

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

52

Dividends paid on certain actively traded or publicly offered
securities1

53

Substitute payments-dividends from certain actively traded or
publicly offered securities1

09
10
11

Capital gains
Industrial royalties

12

Other royalties (e.g., copyright, software, broadcasting,
endorsement payments)

13
14
15
16

Royalties paid on certain publicly offered securities1
Real property income and natural resources royalties
Pensions, annuities, alimony, and/or insurance premiums
Scholarship or fellowship grants

17
18

Compensation for independent personal services2
Compensation for dependent personal services2

19

Compensation for teaching2

Motion picture or television copyright royalties

See back of Copy C for additional codes

1 This 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.
2 If 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.

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/form1042s.

AMENDED

3b Tax rate

4a Exemption code
.

4b Tax rate

.

13f Ch. 3 status code
13h Recipient's GIIN

13g Ch. 4 status code
13i Recipient's foreign tax identification

13k Recipient's account number

8 Tax withheld by other agents

13j LOB code

number, if any

7b Check if tax not deposited with
IRS pursuant to escrow procedure

7a Federal tax withheld

Copy C for Recipient
Attach to any Federal tax return you file

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

5 Withholding allowance
6 Net income

OMB No. 1545-0096

PRO-RATA BASIS REPORTING

3 Chapter indicator. Enter “3” or “4”
3a Exemption code

2016

13l Recipient's date of birth

9 Tax paid by withholding agent
14a Primary Withholding Agent's Name (if applicable)

10 Total withholding credit
11 Amount repaid to recipient
12a Withholding agent’s EIN

14b Primary Withholding Agent's EIN
12b Ch. 3 status code

12c Ch. 4 status code

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

12d Withholding agent's name

15d Intermediary or flow-through entity's name

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

15e Intermediary or flow-through entity's GIIN
15f Country code

12f Country code

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

15g Foreign tax identification number, if any

12g Foreign taxpayer identification number, if any
15h Address (number and street)

12h Address (number and street)
15i City or town, state or province, country, ZIP or foreign postal code
12i City or town, state or province, country, ZIP or foreign postal code
16a Payer's name
13a Recipient's name

16b Payer's TIN

13b Recipient's country code
16c Payer's GIIN

13c Address (number and street)
13d City or town, state or province, country, ZIP or foreign postal code

17a State income tax withheld

16d Ch. 3 status
code

16e Ch. 4 status
code

17b Payer’s state tax no. 17c Name of state
Form 1042-S (2016)

Explanation of Codes (continued)
20
23
24

Compensation during studying and training2
Gross income—Other
Real estate investment trust (REIT) distributions of capital
gains

25

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

26

Other

27
28
32

Publicly traded partnership distributions subject to IRC
section 1446
Gambling winnings3
Notional principal contract income4

35

Substitute payment—other

36

Capital gains distributions

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

37

Return of capital

13
14
15
16
17

38

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

18

39

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

U.S. Payees—of participating FFI or registered deemed-compliant
FFI

19

Exempt from withholding under IGA7

41

Guarantee of indebtedness

20

42

Earnings as an artist or athlete—no central withholding
agreement5

21
22

Dormant account8
Excluded payment on offshore obligation

43

Earnings as an artist or athlete—central withholding
agreement5

44
50
54

Specified Federal procurement payments
Income previously reported under escrow procedure6
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
01
Effectively connected income
02
Exempt under IRC (other than portfolio interest)
03
Income is not from U.S. sources

Grandfathered payment
Effectively connected income
Payee not subject to chapter 4 withholding
Excluded nonfinancial payment
Foreign Entity that assumes primary withholding
responsibility

Excluded payments on Collateral9

Type of Recipient, Withholding Agent, or Intermediary
Code
Chapter 3 Status Codes
01
02
03
04
05
06
07
08
09

U.S. Withholding Agent—FI
U.S. Withholding Agent—Other
Territory FI—treated as U.S. Person
Territory FI—not treated as U.S. Person
U.S. branch—treated as U.S. Person
U.S. branch—not treated as U.S. Person
U.S. branch—ECI presumption applied
Partnership other than Withholding Foreign Partnership
Withholding Foreign Partnership
See back of Copy D for additional codes

2

If 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 to 30% withholding rate unless the recipient is from one of the treaty countries listed under Gambling winnings (Income Code 28) in Pub.
515.
4

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

5

Income Code 43 should only be used if Letter 4492, Venue Notification has been issued by the Internal Revenue Service (otherwise use Income
Code 42 for earnings as an artist or athlete). If 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).

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/form1042s.

AMENDED

3b Tax rate

4a Exemption code
.

4b Tax rate

.

13f Ch. 3 status code
13h Recipient's GIIN

13g Ch. 4 status code
13i Recipient's foreign tax identification

13k Recipient's account number

8 Tax withheld by other agents

13j LOB code

number, if any

7b Check if tax not deposited with
IRS pursuant to escrow procedure

7a Federal tax withheld

Copy D for Recipient
Attach to any state tax return you file

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

5 Withholding allowance
6 Net income

OMB No. 1545-0096

PRO-RATA BASIS REPORTING

3 Chapter indicator. Enter “3” or “4”
3a Exemption code

2016

13l Recipient's date of birth

9 Tax paid by withholding agent
14a Primary Withholding Agent's Name (if applicable)

10 Total withholding credit
11 Amount repaid to recipient
12a Withholding agent’s EIN

14b Primary Withholding Agent's EIN
12b Ch. 3 status code

12c Ch. 4 status code

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

12d Withholding agent's name

15d Intermediary or flow-through entity's name

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

15e Intermediary or flow-through entity's GIIN
15f Country code

12f Country code

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

15g Foreign tax identification number, if any

12g Foreign taxpayer identification number, if any
15h Address (number and street)

12h Address (number and street)
15i City or town, state or province, country, ZIP or foreign postal code
12i City or town, state or province, country, ZIP or foreign postal code
16a Payer's name
13a Recipient's name

16b Payer's TIN

13b Recipient's country code
16c Payer's GIIN

13c Address (number and street)
13d City or town, state or province, country, ZIP or foreign postal code

17a State income tax withheld

16d Ch. 3 status
code

16e Ch. 4 status
code

17b Payer’s state tax no. 17c Name of state
Form 1042-S (2016)

Explanation of Codes (continued)
10
Trust other than Withholding Foreign Trust
11
Withholding Foreign Trust
12
Qualified Intermediary
13
Qualified Securities Lender—Qualified Intermediary
14
Qualified Securities Lender—Other
15
Corporation
16
Individual
17
Estate
18
Private Foundation
19
Government or International Organization
20
Tax Exempt Organization (Section 501(c) entities)
21
Unknown Recipient
22
Artist or Athlete
23
Pension
24
Foreign Central Bank of Issue
25
Nonqualified Intermediary
26
Hybrid entity making Treaty Claim
34
U.S. Withholding Agent—Foreign branch of FI
Pooled Reporting Codes10
27
Withholding Rate Pool—General
28
Withholding Rate Pool—Exempt Organization
29
PAI Withholding Rate Pool—General
30
PAI Withholding Rate Pool—Exempt Organization
31
Agency Withholding Rate Pool—General
32
Agency Withholding Rate Pool—Exempt Organization
33
Joint account withholding rate pool
Chapter 4 Status Codes
01
U.S. Withholding Agent—FI
02
U.S. Withholding Agent—Other
03
Territory FI—not treated as U.S. Person
04
Territory FI—treated as U.S. Person
05
Participating FFI—Other
06
Participating FFI—Reporting Model 2 FFI
07
Registered Deemed-Compliant FFI—Reporting Model 1 FFI

10

08
09
10

Registered Deemed-Compliant FFI—Sponsored Entity
Registered Deemed-Compliant FFI—Other
Certified Deemed-Compliant FFI—Other

11

Certified Deemed-Compliant FFI—FFI with Low Value
Accounts

12

Certified Deemed-Compliant FFI—Non-Registering Local
Bank

13

Certified Deemed-Compliant FFI—Sponsored Entity

14

Certified Deemed-Compliant FFI—Investment Advisor or
Investment Manager

15
16
17
18
19
20

Nonparticipating FFI
Owner-Documented FFI
Limited Branch treated as Nonparticipating FFI
Limited FFI treated as Nonparticipating FFI
Passive NFFE identifying Substantial U.S. Owners
Passive NFFE with no Substantial U.S. Owners

21

Publicly Traded NFFE or Affiliate of Publicly Traded NFFE

22

Active NFFE

23
24
25
26
27

Individual
Section 501(c) Entities
Excepted Territory NFFE
Excepted NFFE — Other
Exempt Beneficial Owner

28
29
30
31
32
33
34
35
36
37
38
39
40

Entity Wholly Owned by Exempt Beneficial Owners
Unknown Recipient
Recalcitrant Account Holder
Nonreporting IGA FFI
Direct reporting NFFE
U.S. reportable account
Non-consenting U.S. account
Sponsored direct reporting NFFE
Excepted Inter-affiliate FFI
Undocumented Preexisting Obligation
U.S. Branch—ECI presumption applied
Account Holder of Excluded Financial Account11
Passive NFFE reported by FFI12

41
50

NFFE subject to 1472 withholding
U.S. Withholding Agent—Foreign branch of FI

Pooled Reporting Codes
42
43
44
45
46
47
48
49

Recalcitrant Pool—No U.S. Indicia
Recalcitrant Pool—U.S. Indicia
Recalcitrant Pool—Dormant Account
Recalcitrant Pool—U.S. Persons
Recalcitrant Pool—Passive NFFEs
Nonparticipating FFI Pool
U.S. Payees Pool
QI-Recalcitrant Pool—GeneraI13

Box 13 j. LOB Code (enter the code that best describes the
applicable limitation on benefits (LOB) category that qualifies the
taxpayer for the requested treaty benefits).
LOB Code

LOB Treaty Category

01
02

Individual
Government – contracting state/political subdivision/local
authority

03
04
05
06
07
08

Tax exempt pension trust/Pension fund
Tax exempt/Charitable organization
Publicly-traded corporation
Subsidiary of publicly-traded corporation
Company that meets the ownership and base erosion test

09

Company with an item of income that meets the active
trade or business test

10
11

Discretionary determination
Other

Company that meets the derivative benefits test

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.
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 its FATCA requirements. The withholding agent must report the name and GIIN of such FFA in boxes 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.

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/form1042s.

AMENDED

3b Tax rate

4a Exemption code
.

4b Tax rate

.

13f Ch. 3 status code
13h Recipient's GIIN

13g Ch. 4 status code
13i Recipient's foreign tax identification

13k Recipient's account number

8 Tax withheld by other agents

13j LOB code

number, if any

7b Check if tax not deposited with
IRS pursuant to escrow procedure

7a Federal tax withheld

Copy E

for Withholding Agent

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

5 Withholding allowance
6 Net income

OMB No. 1545-0096

PRO-RATA BASIS REPORTING

3 Chapter indicator. Enter “3” or “4”
3a Exemption code

2016

13l Recipient's date of birth

9 Tax paid by withholding agent
14a Primary Withholding Agent's Name (if applicable)

10 Total withholding credit
11 Amount repaid to recipient
12a Withholding agent’s EIN

14b Primary Withholding Agent's EIN
12b Ch. 3 status code

12c Ch. 4 status code

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

12d Withholding agent's name

15d Intermediary or flow-through entity's name

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

15e Intermediary or flow-through entity's GIIN
15f Country code

12f Country code

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

15g Foreign tax identification number, if any

12g Foreign taxpayer identification number, if any
15h Address (number and street)

12h Address (number and street)
15i City or town, state or province, country, ZIP or foreign postal code
12i City or town, state or province, country, ZIP or foreign postal code
16a Payer's name
13a Recipient's name

16b Payer's TIN

13b Recipient's country code
16c Payer's GIIN

13c Address (number and street)
13d City or town, state or province, country, ZIP or foreign postal code

17a State income tax withheld

16d Ch. 3 status
code

16e Ch. 4 status
code

17b Payer’s state tax no. 17c Name of state
Form 1042-S (2016)