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pdfForm
1042-S
Foreign Person’s U.S. Source Income Subject to Withholding
▶ Go
to www.irs.gov/Form1042S for instructions and the latest information.
2019
OMB No. 1545-0096
Copy A
for
Department of the Treasury
Internal Revenue Service
Internal Revenue Service
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
1 Income 2 Gross income 3 Chapter indicator. Enter “3” or “4”
13e Recipient's U.S. TIN, if any
13f Ch. 3 status code
code
13g Ch. 4 status code
3a Exemption code
4a Exemption code
13i Recipient's foreign tax identification 13j LOB code
13h Recipient's GIIN
3b Tax rate
.
4b Tax rate
.
number, if any
5 Withholding allowance
6 Net income
7a Federal tax withheld
13k Recipient's account number
7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) . . . . . .
13l Recipient's date of birth (YYYYMMDD)
7c Check if withholding occurred in subsequent year with respect to a
partnership interest . . . . . . . . . . . . .
.
14a Primary Withholding Agent's Name (if applicable)
8 Tax withheld by other agents
9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
(
)
14b Primary Withholding Agent's EIN
10 Total withholding credit (combine boxes 7a, 8, and 9)
15 Check if pro-rata basis reporting
15a Intermediary or flow-through entity's EIN, if any 15b Ch. 3 status code 15c Ch. 4 status code
11 Tax paid by withholding agent (amounts not withheld) (see instructions)
15d Intermediary or flow-through entity's name
12a Withholding agent's EIN
12b Ch. 3 status code 12c Ch. 4 status code
12d Withholding agent's name
15e Intermediary or flow-through entity's GIIN
15f Country code
15g Foreign tax identification number, if any
12e Withholding agent's Global Intermediary Identification Number (GIIN)
15h Address (number and street)
12f Country code
15i City or town, state or province, country, ZIP or foreign postal code
12g Foreign tax identification number, if any
12h Address (number and street)
16a Payer's name
12i City or town, state or province, country, ZIP or foreign postal code
16c Payer's GIIN
13a Recipient's name
17a State income tax withheld
13b Recipient's country code
16b Payer's TIN
16d Ch. 3 status code
16e Ch. 4 status code
17b Payer's state tax no. 17c Name of state
13c Address (number and street)
13d City or town, state or province, country, ZIP or foreign postal code
For Privacy Act and Paperwork Reduction Act Notice, see instructions.
Cat. No. 11386R
Form 1042-S (2019)
Form
1042-S
Foreign Person’s U.S. Source Income Subject to Withholding
▶ Go
to www.irs.gov/Form1042S for instructions and the latest information.
2019
OMB No. 1545-0096
Copy B
Department of the Treasury
for Recipient
Internal Revenue Service
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
1 Income 2 Gross income 3 Chapter indicator. Enter “3” or “4”
13e Recipient's U.S. TIN, if any
13f Ch. 3 status code
code
13g Ch. 4 status code
3a Exemption code
4a Exemption code
13i Recipient's foreign tax identification 13j LOB code
13h Recipient's GIIN
3b Tax rate
.
4b Tax rate
.
number, if any
5 Withholding allowance
6 Net income
7a Federal tax withheld
13k Recipient's account number
7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) . . . . . .
13l Recipient's date of birth (YYYYMMDD)
7c Check if withholding occurred in subsequent year with respect to a
partnership interest . . . . . . . . . . . . .
.
14a Primary Withholding Agent's Name (if applicable)
8 Tax withheld by other agents
9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
(
)
14b Primary Withholding Agent's EIN
10 Total withholding credit (combine boxes 7a, 8, and 9)
15 Check if pro-rata basis reporting
15a Intermediary or flow-through entity's EIN, if any 15b Ch. 3 status code 15c Ch. 4 status code
11 Tax paid by withholding agent (amounts not withheld) (see instructions)
15d Intermediary or flow-through entity's name
12a Withholding agent's EIN
12b Ch. 3 status code 12c Ch. 4 status code
12d Withholding agent's name
15e Intermediary or flow-through entity's GIIN
15f Country code
15g Foreign tax identification number, if any
12e Withholding agent's Global Intermediary Identification Number (GIIN)
15h Address (number and street)
12f Country code
15i City or town, state or province, country, ZIP or foreign postal code
12g Foreign tax identification number, if any
12h Address (number and street)
16a Payer's name
12i City or town, state or province, country, ZIP or foreign postal code
16c Payer's GIIN
13a Recipient's name
17a State income tax withheld
13b Recipient's country code
16b Payer's TIN
16d Ch. 3 status code
16e Ch. 4 status code
17b Payer's state tax no. 17c Name of state
13c Address (number and street)
13d City or town, state or province, country, ZIP or foreign postal code
(keep for your records)
Form 1042-S (2019)
U.S. Income Tax Filing Requirements
Generally, every nonresident alien individual, nonresident alien
fiduciary, and foreign corporation with U.S. income, including income
that is effectively connected with the conduct of a trade or business in
the United States, must file a U.S. 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 U.S. tax at the source. Corporations file
Form 1120-F; all others file Form 1040NR. You may get the return
forms and instructions at IRS.gov, at any U.S. 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. On peut se procurer
les formulaires de déclarations d’impôts et les instructions y afférentes
à IRS.gov et 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. Se podrá obtener
formularios e instrucciones en IRS.gov y 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 ein.
Einkommensteuererklärungen und Instruktionen können unter IRS.gov
und bei den Botschaften und Konsulaten der Vereinigten Staaten
eingeholt werden. Um weitere Informationen wende man sich bitte an:
Internal Revenue Service, 1201 N. Mitsubishi Motorway,
Bloomington, IL 61705-6613.
01
Dividend
Interest
02
03
04
05
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
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
51
Interest paid on certain actively traded or publicly offered
securities1
54
Substitute payments—interest from certain actively traded
or publicly offered securities1
06
07
08
Dividends paid by U.S. corporations—general
Dividends qualifying for direct dividend rate
Dividends paid by foreign corporations
Other
Box 1. Income Code.
Code
Dividend
Explanation of Codes
34
Substitute payment—dividends
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
Motion picture or television copyright royalties
12
Other royalties (for example, copyright, software,
broadcasting, endorsement payments)
13
Royalties paid on certain publicly offered securities1
14
15
16
17
Real property income and natural resources royalties
Pensions, annuities, alimony, and/or insurance premiums
Scholarship or fellowship grants
Compensation for independent personal services2
18
19
Compensation for dependent personal services2
Compensation for teaching2
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
▶ Go
to www.irs.gov/Form1042S for instructions and the latest information.
2019
OMB No. 1545-0096
Copy C
for Recipient
Department of the Treasury
Attach to any Federal tax return you file
Internal Revenue Service
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
1 Income 2 Gross income 3 Chapter indicator. Enter “3” or “4”
13e Recipient's U.S. TIN, if any
13f Ch. 3 status code
code
13g Ch. 4 status code
3a Exemption code
4a Exemption code
13i Recipient's foreign tax identification 13j LOB code
13h Recipient's GIIN
3b Tax rate
.
4b Tax rate
.
number, if any
5 Withholding allowance
6 Net income
7a Federal tax withheld
13k Recipient's account number
7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) . . . . . .
13l Recipient's date of birth (YYYYMMDD)
7c Check if withholding occurred in subsequent year with respect to a
partnership interest . . . . . . . . . . . . .
.
14a Primary Withholding Agent's Name (if applicable)
8 Tax withheld by other agents
9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
(
)
14b Primary Withholding Agent's EIN
10 Total withholding credit (combine boxes 7a, 8, and 9)
15 Check if pro-rata basis reporting
15a Intermediary or flow-through entity's EIN, if any 15b Ch. 3 status code 15c Ch. 4 status code
11 Tax paid by withholding agent (amounts not withheld) (see instructions)
15d Intermediary or flow-through entity's name
12a Withholding agent's EIN
12b Ch. 3 status code 12c Ch. 4 status code
12d Withholding agent's name
15e Intermediary or flow-through entity's GIIN
15f Country code
15g Foreign tax identification number, if any
12e Withholding agent's Global Intermediary Identification Number (GIIN)
15h Address (number and street)
12f Country code
15i City or town, state or province, country, ZIP or foreign postal code
12g Foreign tax identification number, if any
12h Address (number and street)
16a Payer's name
12i City or town, state or province, country, ZIP or foreign postal code
16c Payer's GIIN
13a Recipient's name
17a State income tax withheld
13b Recipient's country code
16b Payer's TIN
16d Ch. 3 status code
16e Ch. 4 status code
17b Payer's state tax no. 17c Name of state
13c Address (number and street)
13d City or town, state or province, country, ZIP or foreign postal code
Form 1042-S (2019)
Other
Explanation of Codes (continued)
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
22
QDD that assumes primary withholding responsibility
23
Exempt under section 897(l)
Chapter 4
13
Grandfathered payment
14
Effectively connected income
15
Payee not subject to chapter 4 withholding
16
Excluded nonfinancial payment
20
Compensation during studying and training2
23
Other income
24
Qualified investment entity (QIE) distributions of capital
gains
25
Trust distributions subject to IRC section 1445
26
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
32
35
36
37
Gambling winnings3
Notional principal contract income4
Substitute payment—other
Capital gains distributions
Return of capital
17
38
Eligible deferred compensation items subject to IRC section
877A(d)(1)
Foreign Entity that assumes primary withholding
responsibility
18
39
Distributions from a nongrantor trust subject to IRC section
877A(f)(1)
U.S. Payees—of participating FFI or registered deemedcompliant FFI
19
Exempt from withholding under IGA7
41
Guarantee of indebtedness
20
Dormant account8
42
Earnings as an artist or athlete—no central withholding
agreement5
21
Other—payment not subject to chapter 4 withholding
43
Earnings as an artist or athlete—central withholding
agreement5
44
50
Specified federal procurement payments
Income previously reported under escrow procedure6
55
Taxable death benefits on life insurance contracts
Boxes 3a and 4a. Exemption Code (applies if the tax rate entered
in box 3b or 4b is 00.00).
Code
Authority for Exemption
Chapter 3
Effectively connected income
01
02
03
04
05
Exempt under IRC (other than portfolio interest)
Income is not from U.S. sources
Exempt under tax treaty
Portfolio interest exempt under IRC
Boxes 12b, 12c, 13f, 13g, 15b, 15c, 16d, and 16e. Withholding
Agent, Recipient, Intermediary, and Payer Chapter 3 and Chapter
4 Status Codes.
Type of Recipient, Withholding Agent, Payer, or Intermediary
Code
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—ECI presumption applied
08
Partnership other than Withholding Foreign Partnership
09
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
8
Use only to report a U.S. reportable account or nonconsenting U.S. account that is receiving a payment subject to chapter 3 withholding.
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 box 7b (“tax not deposited with IRS pursuant to escrow procedure”). You must instead enter “3” in box 3 and complete box 3b.
Form
1042-S
Foreign Person’s U.S. Source Income Subject to Withholding
▶ Go
to www.irs.gov/Form1042S for instructions and the latest information.
2019
OMB No. 1545-0096
Copy D
for Recipient
Department of the Treasury
Attach to any state tax return you file
Internal Revenue Service
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
1 Income 2 Gross income 3 Chapter indicator. Enter “3” or “4”
13e Recipient's U.S. TIN, if any
13f Ch. 3 status code
code
13g Ch. 4 status code
3a Exemption code
4a Exemption code
13i Recipient's foreign tax identification 13j LOB code
13h Recipient's GIIN
3b Tax rate
.
4b Tax rate
.
number, if any
5 Withholding allowance
6 Net income
7a Federal tax withheld
13k Recipient's account number
7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) . . . . . .
13l Recipient's date of birth (YYYYMMDD)
7c Check if withholding occurred in subsequent year with respect to a
partnership interest . . . . . . . . . . . . .
.
14a Primary Withholding Agent's Name (if applicable)
8 Tax withheld by other agents
9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
(
)
14b Primary Withholding Agent's EIN
10 Total withholding credit (combine boxes 7a, 8, and 9)
15 Check if pro-rata basis reporting
15a Intermediary or flow-through entity's EIN, if any 15b Ch. 3 status code 15c Ch. 4 status code
11 Tax paid by withholding agent (amounts not withheld) (see instructions)
15d Intermediary or flow-through entity's name
12a Withholding agent's EIN
12b Ch. 3 status code 12c Ch. 4 status code
12d Withholding agent's name
15e Intermediary or flow-through entity's GIIN
15f Country code
15g Foreign tax identification number, if any
12e Withholding agent's Global Intermediary Identification Number (GIIN)
15h Address (number and street)
12f Country code
15i City or town, state or province, country, ZIP or foreign postal code
12g Foreign tax identification number, if any
12h Address (number and street)
16a Payer's name
12i City or town, state or province, country, ZIP or foreign postal code
16c Payer's GIIN
13a Recipient's name
17a State income tax withheld
13b Recipient's country code
16b Payer's TIN
16d Ch. 3 status code
16e Ch. 4 status code
17b Payer's state tax no. 17c Name of state
13c Address (number and street)
13d City or town, state or province, country, ZIP or foreign postal code
Form 1042-S (2019)
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
35
Qualified Derivatives Dealer
Pooled Reporting Codes9
27
28
29
30
31
32
Withholding Rate Pool—General
Withholding Rate Pool—Exempt Organization
PAI Withholding Rate Pool—General
PAI Withholding Rate Pool—Exempt Organization
Agency Withholding Rate Pool—General
Agency Withholding Rate Pool—Exempt Organization
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
08
Registered Deemed-Compliant FFI—Sponsored Entity
09
Registered Deemed-Compliant FFI—Other
10
Certified Deemed-Compliant FFI—Other
9
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
Passive NFFE with no Substantial U.S. Owners
Publicly Traded NFFE or Affiliate of Publicly Traded NFFE
Active NFFE
Individual
Section 501(c) Entities
Excepted Territory NFFE
Excepted NFFE—Other
Exempt Beneficial Owner
Entity Wholly Owned by Exempt Beneficial Owners
Unknown Recipient
Recalcitrant Account Holder
Nonreporting IGA FFI
Direct reporting NFFE
U.S. reportable account
Nonconsenting 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 Account10
Passive NFFE reported by FFI11
41
NFFE subject to 1472 withholding
50
U.S. Withholding Agent—Foreign branch of FI
Pooled Reporting Codes
42
Recalcitrant Pool—No U.S. Indicia
43
Recalcitrant Pool—U.S. Indicia
44
Recalcitrant Pool—Dormant Account
45
Recalcitrant Pool—U.S. Persons
46
Recalcitrant Pool—Passive NFFEs
47
Nonparticipating FFI Pool
48
U.S. Payees Pool
49
QI-Recalcitrant Pool—GeneraI12
Box 13j. 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
02
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
Company that meets the derivative benefits test
11
Certified Deemed-Compliant FFI—FFI with Low Value
Accounts
12
Certified Deemed-Compliant FFI—Nonregistering Local
Bank
13
Certified Deemed-Compliant FFI—Sponsored Entity
14
Certified Deemed-Compliant FFI—Investment Entity that
does not maintain financial accounts
09
Company with an item of income that meets the active trade
or business test
15
16
Nonparticipating FFI
Owner-Documented FFI
10
11
Discretionary determination
Other
17
U.S. Branch—treated as U.S. person
18
U.S. Branch—not treated as U.S. person (reporting under
section 1471)
19
Passive NFFE identifying Substantial U.S. Owners
Codes 27 through 32 should only be used by a QI, QSL, WP, or WT. A QI acting as a QDD may use code 27 or 28.
10
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.
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 deemedcompliant 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.
11
12
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
▶ Go
to www.irs.gov/Form1042S for instructions and the latest information.
2019
OMB No. 1545-0096
Copy E
Department of the Treasury
for Withholding Agent
Internal Revenue Service
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
1 Income 2 Gross income 3 Chapter indicator. Enter “3” or “4”
13e Recipient's U.S. TIN, if any
13f Ch. 3 status code
code
13g Ch. 4 status code
3a Exemption code
4a Exemption code
13i Recipient's foreign tax identification 13j LOB code
13h Recipient's GIIN
3b Tax rate
.
4b Tax rate
.
number, if any
5 Withholding allowance
6 Net income
7a Federal tax withheld
13k Recipient's account number
7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) . . . . . .
13l Recipient's date of birth (YYYYMMDD)
7c Check if withholding occurred in subsequent year with respect to a
partnership interest . . . . . . . . . . . . .
.
14a Primary Withholding Agent's Name (if applicable)
8 Tax withheld by other agents
9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
(
)
14b Primary Withholding Agent's EIN
10 Total withholding credit (combine boxes 7a, 8, and 9)
15 Check if pro-rata basis reporting
15a Intermediary or flow-through entity's EIN, if any 15b Ch. 3 status code 15c Ch. 4 status code
11 Tax paid by withholding agent (amounts not withheld) (see instructions)
15d Intermediary or flow-through entity's name
12a Withholding agent's EIN
12b Ch. 3 status code 12c Ch. 4 status code
12d Withholding agent's name
15e Intermediary or flow-through entity's GIIN
15f Country code
15g Foreign tax identification number, if any
12e Withholding agent's Global Intermediary Identification Number (GIIN)
15h Address (number and street)
12f Country code
15i City or town, state or province, country, ZIP or foreign postal code
12g Foreign tax identification number, if any
12h Address (number and street)
16a Payer's name
12i City or town, state or province, country, ZIP or foreign postal code
16c Payer's GIIN
13a Recipient's name
17a State income tax withheld
13b Recipient's country code
16b Payer's TIN
16d Ch. 3 status code
16e Ch. 4 status code
17b Payer's state tax no. 17c Name of state
13c Address (number and street)
13d City or town, state or province, country, ZIP or foreign postal code
For Privacy Act and Paperwork Reduction Act Notice, see instructions.
Form 1042-S (2019)
File Type | application/pdf |
File Title | 2019 Form 1042-S |
Subject | Fillable |
Author | SE:W:CAR:MP |
File Modified | 2018-11-29 |
File Created | 2018-11-29 |