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

U.S. Business Income Tax Return

f1042-s--2021-00-00

OMB: 1545-0123

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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.

2021

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 (2021)

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.

2021

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

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 (2021)

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 1040-NR. 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 1040-NR. 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 1040-NR. 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 1040-NR 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.
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

09
10
11

Capital gains
Industrial royalties
Motion picture or television copyright royalties

Other royalties (for example, copyright, software,
broadcasting, endorsement payments)

13
14
15
16
17

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
Compensation for independent personal services2

18
19

Compensation for dependent personal services2
Compensation for teaching2

Dividend

01
02
03
04
05

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

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

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

Types of Income

Dividend

Box 1. Income Code.
Code

Interest

Explanation of Codes

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 the 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.

2021

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

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 (2021)

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)
Exempt under section 892
24
Chapter 4
13
Grandfathered payment
14
Effectively connected income
15
Payee not subject to chapter 4 withholding
16
Excluded nonfinancial payment

Compensation during studying and training2

Other income

Qualified investment entity (QIE) 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

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

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

Foreign Entity that assumes primary withholding
responsibility

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

U.S. Payees—of participating FFI or registered deemedcompliant FFI

Guarantee of indebtedness

Earnings as an artist or athlete—no central withholding
agreement5

19
20

Exempt from withholding under IGA8
Dormant account9

Other—payment not subject to chapter 4 withholding

Earnings as an artist or athlete—central withholding
agreement5

44
50

Specified federal procurement payments
Income previously reported under escrow procedure6

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
01
Effectively connected income
02
Exempt under IRC7
03
04
05

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
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.

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

This code should only be used if no other specific chapter 3 exemption code applies.

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.

2021

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

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 (2021)

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
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
35
Qualified Derivatives Dealer
36
Foreign Government—Integral Part
37
Foreign Government—Controlled Entity
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
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

20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39

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 Account11

40
Passive NFFE reported by FFI12
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—GeneraI13
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

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

Certified Deemed-Compliant FFI—FFI with Low Value
Accounts

Certified Deemed-Compliant FFI—Nonregistering Local
Bank

Certified Deemed-Compliant FFI—Sponsored Entity

Certified Deemed-Compliant FFI—Investment Entity that
does not maintain financial accounts

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

15
16
17

Nonparticipating FFI
Owner-Documented FFI
U.S. Branch—treated as U.S. person

10
11

Discretionary determination
Other

U.S. Branch—not treated as U.S. person (reporting under
section 1471)

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.

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 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 FFI 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
▶ Go

to www.irs.gov/Form1042S for instructions and the latest information.

2021

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

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 (2021)

File Type	application/pdf
File Title	2021 Form 1042-S
Subject	Fillable
Author	SE:W:CAR:MP
File Modified	2020-11-10
File Created	2020-11-10