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

1042

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

Form
Department of the Treasury
Internal Revenue Service

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Ch. 3 Status Code

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Ch. 4 Status Code

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

If you do not expect to file this return in the future, check here

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For IRS Use Only
CC
RD
CAF
CR
EDC

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

Period
ending

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Employer identification number

Name of withholding agent

Line
No.

2016

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

If this is an amended return, check here .

Section 1

OMB No. 1545-0096

Enter date final income paid

FD
FF
FP
I
SIC
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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

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

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
29
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
33
22
22
54
30
34
31
31
55 Nov. total
35 July total
Mar. total
56
7
36
7
7
57
15
37
15
15
Apr.
Aug.
Dec.
58
22
38
22
22
59
31
39
31
30
60 Dec. total
40 Aug. total
Apr. 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

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

No

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 ▶

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Firm’s address ▶

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

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Phone no.
Cat. No. 11384V

Form 1042 (2016)

Page 2

Form 1042 (2016)

63
a
b

c

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

Total tax reported as withheld or paid by withholding agent on all Forms 1042-S and 1000:
Tax withheld by withholding agent
. . . . . . . . . . . . . . . . . . .
Tax withheld by other withholding agents:
(1) For payments other than substitute dividends . . . . . . . . . . . . . . .
(2) For substitute dividends . . . . . . . . . . . . . . . . . . . . . .
Adjustments to withholding:
(1) Adjustments to overwithholding . . . . . . . . . . . . . . . . . . .
(2) Adjustments to underwithholding . . . . . . . . . . . . . . . . . . .
Tax paid by withholding agent . . . . . . . . . . . . . . . . . . . . .
Total tax reported as withheld or paid (Add lines 63a-d) . . . . . . . . . . . .
Total net tax liability
Adjustments to total net tax liability . . . . . . . . . . . . . . . . . . .
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 64a-d) . . . . . . . . . . . . . . . . . .
Total paid by electronic funds transfer (or with a request for extension of time to file):
Total paid during calendar year . . . . . . . . . . . . . . . . . . . . .
Total paid during subsequent year . . . . . . . . . . . . . . . . . . . .
Enter overpayment applied as credit from 2015 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 . . . . . . . . . . . . .
Enter overpayment attributable to overwithholding on U.S. source income of foreign persons
Enter overpayment attributable to excise tax on specified federal procurement payments .
Apply overpayment (sum of lines 70a and 70b) to (check one):
Credit on 2017 Form 1042
or
Refund

Section 2
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63a

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63b(1)
63b(2)

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

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64a
64b
64c
64d
64e

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65a
65b
66

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67a
67b
68
69
70a
70b

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 required to be reported under chapter 4 but 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 . . . . . . . . . . . . . . . . . . . .
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 Amount of excluded payments on offshore obligations . . . . . . . . . . . . . . . .
f Amount of excluded payments on collateral . . . . . . . . . . . . . . . . . . .
g Total U.S. source FDAP income required to be reported under chapter 4 but not required to be withheld
upon under chapter 4 (Add lines 2a-f) . . . . . . . . . . . . . . . . . . . . . .
3
Total U.S. source FDAP income reportable under chapter 4 (Add lines 1 and 2g) . . . . . . .
4
Total U.S. source FDAP income reported on all Forms 1042-S (from line 62a, (b)(1), and (b)(2)) . . .
5
Total variance, subtract line 3 from line 4, if amount other than zero, provide explanation on line 6 . .
6

Section 3

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1

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

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 (2016)