2027 Form 1042-S

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TREASURY/IRS AND OMB USE ONLY DRAFT
Form

1042-S

2027

Foreign Person’s U.S. Source Income Subject to Withholding
Go to www.irs.gov/Form1042S for instructions and the latest information.

Department of the Treasury
Internal Revenue Service

UNIQUE FORM IDENTIFIER

1 Income 2 Gross income 3 Chapter indicator. Enter “3” or “4”
code
3a Exemption code
4a Exemption code
3b Tax rate

.

4b Tax rate

.

AMENDED

OMB No. 1545-0096

Copy A for
Internal Revenue Service

AMENDMENT NO.

13i Recipient’s U.S. TIN, if any

13j Ch. 3 status code

13l Recipient’s GIIN

13m Recipient’s FTIN, if any

13k Ch. 4 status code

5 Withholding allowance
6 Net income
7a Federal tax withheld

13n LOB code

7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied. See instructions . . . . . .

13p Recipient’s date of birth (YYYYMMDD)

7c Check if withholding occurred in subsequent year with respect to a
partnership interest . . . . . . . . . . . . .

.

7d Check if you are a qualified intermediary, withholding foreign
partnership, or withholding foreign trust revising its reporting on Form
1042-S to report to a specific recipient . . . . . . . . .

14a Primary withholding agent’s name (if applicable)
14b Primary withholding agent’s EIN

8 Tax withheld by other agents
9 Overwithheld tax repaid to recipient pursuant
to adjustment procedures (see instructions)

(

10 Total withholding credit
(combine boxes 7a, 8, and 9)

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

15 Check if pro-rata basis reporting
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

15e Intermediary or flow-through entity’s GIIN

12b Ch. 3 status code
12c Ch. 4 status code

12d Withholding agent’s name

15f Country code

12e Withholding agent’s global intermediary identification number (GIIN)

15h Address (number and street)

12f Country code

15i Room or suite no.

15j City or town

12h Address (number and street)

15k State or province

15l Country

12i Room or suite no.

12j City or town

16a Payer’s name

12k State or province

12l Country

12g FTIN, if any

15g FTIN, if any

12m ZIP or foreign postal code

16c Payer’s GIIN

13b Recipient’s country code

17a State income tax withheld

15m ZIP or foreign postal code
16b Payer’s TIN
16d Ch. 3 status code
16e Ch. 4 status code

13a Recipient’s name

17b Payer’s state tax no.

17c Name of state

13c Address (number and street)
13d Apt. no.

13e City or town

13f State or province

13g Country

13h ZIP or foreign postal code

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

Cat. No. 11386R

Form 1042-S (2027) Created 6/9/26

DRAFT — DO NOT FILE

DRAFT — DO NOT FILE

13o Recipient’s account number

TREASURY/IRS AND OMB USE ONLY DRAFT
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.

Department of the Treasury
Internal Revenue Service

UNIQUE FORM IDENTIFIER

1 Income 2 Gross income 3 Chapter indicator. Enter “3” or “4”
code
3a Exemption code
4a Exemption code
3b Tax rate

.

4b Tax rate

.

AMENDED

2027

OMB No. 1545-0096

Copy B

for Recipient

AMENDMENT NO.

13i Recipient’s U.S. TIN, if any

13j Ch. 3 status code

13l Recipient’s GIIN

13m Recipient’s FTIN, if any

13k Ch. 4 status code

5 Withholding allowance
6 Net income
7a Federal tax withheld

13n LOB code

7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied. See instructions . . . . . .

13p Recipient’s date of birth (YYYYMMDD)

7c Check if withholding occurred in subsequent year with respect to a
partnership interest . . . . . . . . . . . . .

.

7d Check if you are a qualified intermediary, withholding foreign
partnership, or withholding foreign trust revising its reporting on Form
1042-S to report to a specific recipient . . . . . . . . .

14a Primary withholding agent’s name (if applicable)
14b Primary withholding agent’s EIN

8 Tax withheld by other agents
9 Overwithheld tax repaid to recipient pursuant
to adjustment procedures (see instructions)

(

10 Total withholding credit
(combine boxes 7a, 8, and 9)

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

15 Check if pro-rata basis reporting
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

15e Intermediary or flow-through entity’s GIIN

12b Ch. 3 status code
12c Ch. 4 status code

12d Withholding agent’s name

15f Country code

12e Withholding agent’s global intermediary identification number (GIIN)

15h Address (number and street)

12f Country code

15i Room or suite no.

15j City or town

12h Address (number and street)

15k State or province

15l Country

12i Room or suite no.

12j City or town

16a Payer’s name

12k State or province

12l Country

12g FTIN, if any

15g FTIN, if any

12m ZIP or foreign postal code

16c Payer’s GIIN

13b Recipient’s country code

17a State income tax withheld

15m ZIP or foreign postal code
16b Payer’s TIN
16d Ch. 3 status code
16e Ch. 4 status code

13a Recipient’s name

17b Payer’s state tax no.

17c Name of state

13c Address (number and street)
13d Apt. no.

13e City or town

13f State or province

13g Country

(keep for your records)

13h ZIP or foreign postal code
Form 1042-S (2027)

DRAFT — DO NOT FILE

DRAFT — DO NOT FILE

13o Recipient’s account number

TREASURY/IRS AND OMB USE ONLY DRAFT
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, a
return is generally not 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. See the
instructions for Forms 1120-F and 1040-NR for more information.
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, toute personne physique étrangère non
résidente, tout fiduciaire étranger non résident et toute société
étrangère ayant des revenus américains, y compris des revenus
effectivement liés à la conduite d’un commerce ou d’une entreprise
aux États-Unis, doit déposer une déclaration d’impôt sur le revenu
aux États-Unis. Toutefois, une déclaration n’est généralement pas
requise de la part d’un particulier étranger non résident, d’un
fiduciaire étranger non résident ou d’une société étrangère si cette
personne n’a pas exercé d’activité commerciale aux États-Unis à un
moment quelconque de l’année fiscale et si l’obligation fiscale de
cette personne a été entièrement satisfaite par la retenue à la source
de l’impôt américain. Voir les instructions des formulaires 1120F et
1040NR pour plus d’informations. Les sociétés déposent le formulaire
1120-F; toutes les autres déposent le formulaire 1040-NR. Vous
pouvez obtenir les formulaires de déclaration et les instructions sur le
site IRS.gov, dans n’importe quel bureau de poste des États-Unis, ou
en écrivant à l’ambassade ou au consulat de l’Union européenne:
Internal Revenue Service, 1201 N. Mitsubishi Motorway, Bloomington,
IL 61705-6613.

Por lo general, toda persona que es un extranjero no residente,
todo fiduciario extranjero no residente, y toda sociedad anónima
extranjera que perciba ingresos estadounidenses, inclusive de los
ingresos que son efectivamente conectados con la operación de un
comercio o negocio ubicado en los Estados Unidos, debe presentar
una declaración del impuesto estadounidense sobre los ingresos. Sin
embargo, por lo general no se requiere que un individuo extranjero no
residente, una sociedad anónima extranjera u organismo
fideicomisario extranjero no residente presenten una declaración si
dicha persona no participaba en ningún comercio o negocio ubicado
en los Estados Unidos en ningún momento durante el año tributario, y
la responsabilidad tributaria de dicha persona fuera liquidada
completamente mediante la retención del impuesto estadounidense
en la fuente del ingreso. Consulte las instrucciones de los Formularios
1120F y 1040-NR para obtener más información. Las sociedades
anónimas presentan el Formulario 1120-F, todos los demás presentan
el Formulario 1040-NR. Puede obtener los formularios de declaración
y sus instrucciones en IRS.gov, en cualquier embajada o consulado
de los Estados Unidos, o al escribir al: Internal Revenue Service, 1201
N. Mitsubishi Motorway, Bloomington, IL 61705-6613.
Grundsätzlich muss jede natürliche Person ohne Wohnsitz im Land,
jeder Treuhänder ohne Wohnsitz im Land und jede ausländische
Gesellschaft mit Einkünften in den USA, einschließlich Einkünften, die
tatsächlich mit der Ausübung einer gewerblichen oder geschäftlichen
Tätigkeit in den Vereinigten Staaten in Zusammenhang stehen, eine
US-Einkommensteuererklärung einreichen. Eine Steuererklärung muss
jedoch von einem nicht in den USA ansässigen Ausländer, einem nicht
in den USA ansässigen Treuhänder oder einem ausländischen
Unternehmen im Allgemeinen nicht eingereicht werden, wenn diese
Person zu keinem Zeitpunkt während des Steuerjahres in den
Vereinigten Staaten einer gewerblichen oder geschäftlichen Tätigkeit
nachgegangen ist und die Steuerschuld dieser Person durch den
Einbehalt der US-Quellensteuer vollständig beglichen wurde. Weitere
Informationen finden Sie in den Anweisungen für die Formulare 1120F
und 1040NR. Unternehmen reichen das Formular 1120-F ein, alle
anderen reichen das Formular 1040-NR ein. Sie können die
Rücksendeformulare und Anweisungen auf IRS.gov erhalten, auf jeder
US-Botschaft oder Konsulat oder schriftlich an: Internal Revenue
Service, 1201 N. Mitsubishi Motorway, Bloomington, IL 61705-6613.

Dividend

Types of Income

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

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

Interest

Box 1. Income Code.
Code

Dividend

Explanation of Codes

34
40

Substitute payment—dividends
Other dividend equivalents under IRC section 871(m)

52

Dividends paid on certain actively traded or publicly offered
securities1

53

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

56

Dividend equivalents under IRC section 871(m) as a result of
applying the combined transaction rules

09
10
11

Capital gains
Industrial royalties
Motion picture or television copyright royalties

12

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

13
14
15
16
17
18

Royalties paid on certain publicly offered securities1
Real property income and natural resources royalties
Pensions
Scholarship or fellowship grants
Compensation for independent personal services2
Compensation for dependent personal services2

19

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 the withholding agent has reduced the rate of withholding

under an income tax treaty without the recipient providing a U.S. TIN or an FTIN.

2 If compensation that would otherwise 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.

DRAFT — DO NOT FILE

DRAFT — DO NOT FILE

U.S. Income Tax Filing Requirements

TREASURY/IRS AND OMB USE ONLY DRAFT
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.

Department of the Treasury
Internal Revenue Service

UNIQUE FORM IDENTIFIER

1 Income 2 Gross income 3 Chapter indicator. Enter “3” or “4”
code
3a Exemption code
4a Exemption code
3b Tax rate

.

4b Tax rate

.

AMENDED

2027
AMENDMENT NO.

OMB No. 1545-0096

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

13i Recipient’s U.S. TIN, if any

13j Ch. 3 status code

13l Recipient’s GIIN

13m Recipient’s FTIN, if any

13k Ch. 4 status code

5 Withholding allowance
6 Net income
7a Federal tax withheld

13n LOB code

7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied. See instructions . . . . . .

13p Recipient’s date of birth (YYYYMMDD)

7c Check if withholding occurred in subsequent year with respect to a
partnership interest . . . . . . . . . . . . .

.

7d Check if you are a qualified intermediary, withholding foreign
partnership, or withholding foreign trust revising its reporting on Form
1042-S to report to a specific recipient . . . . . . . . .

14a Primary withholding agent’s name (if applicable)
14b Primary withholding agent’s EIN

8 Tax withheld by other agents
9 Overwithheld tax repaid to recipient pursuant
to adjustment procedures (see instructions)

(

10 Total withholding credit
(combine boxes 7a, 8, and 9)

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

15 Check if pro-rata basis reporting
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

15e Intermediary or flow-through entity’s GIIN

12b Ch. 3 status code
12c Ch. 4 status code

12d Withholding agent’s name

15f Country code

12e Withholding agent’s global intermediary identification number (GIIN)

15h Address (number and street)

12f Country code

15i Room or suite no.

15j City or town

12h Address (number and street)

15k State or province

15l Country

12i Room or suite no.

12j City or town

16a Payer’s name

12k State or province

12l Country

12g FTIN, if any

15g FTIN, if any

12m ZIP or foreign postal code

16c Payer’s GIIN

13b Recipient’s country code

17a State income tax withheld

15m ZIP or foreign postal code
16b Payer’s TIN
16d Ch. 3 status code
16e Ch. 4 status code

13a Recipient’s name

17b Payer’s state tax no.

17c Name of state

13c Address (number and street)
13d Apt. no.

13e City or town

13f State or province

13g Country

13h ZIP or foreign postal code
Form 1042-S (2027)

DRAFT — DO NOT FILE

DRAFT — DO NOT FILE

13o Recipient’s account number

TREASURY/IRS AND OMB USE ONLY DRAFT

Other

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(a)

28
32
35
36
37

Gambling winnings3
Notional principal contract income4
Substitute payment—other
Capital gains distributions
Return of capital

38

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

39

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

41

Guarantee of indebtedness

42

04
05
06
07
08
10
11
12
22
23
24

Exempt or reduced withholding under tax treaty
Portfolio interest exempt under IRC
QI that assumes primary withholding responsibility
Withholding foreign partnership or withholding foreign trust
U.S. branch treated as U.S. person
QI represents that income is exempt
QSL that assumes primary withholding responsibility
Payee subjected to chapter 4 withholding
QDD that assumes primary withholding responsibility
Exempt under section 897(l)
Exempt under section 892

Box 4a. Exemption Code (applies if the tax rate entered in box 4b
is 00.00).
Code
Chapter 4 Authority for Exemption
13
14
15
16
17

Grandfathered payment
Effectively connected income
Payee not subject to chapter 4 withholding
Excluded nonfinancial payment

Earnings as an artist or athlete—no central withholding
agreement5

18

U.S. payees of participating FFI or registered deemedcompliant FFI

43

Earnings as an artist or athlete—central withholding
agreement5

44
50

Specified federal procurement payments
Income previously reported under escrow procedure6

19
20
21

Exempt from withholding under IGA8
Dormant account9
Other payment not subject to chapter 4 withholding

55
57
58
59
60
61
62
63
64
65

Taxable death benefits on life insurance contracts
Amount realized under IRC section 1446(f)
Publicly traded partnership distributions—undetermined
Consent fees
Loan syndication fees
Settlement payments
Annuities
Alimony
Insurance premiums
Social security benefits

Box 3a. Exemption Code (applies if withholding is applied at a
reduced rate or if payment is exempt from withholding).
Code
Chapter 3 Authority for Exemption or Reduced Rate of
Withholding
01
02

Effectively connected income
Exempt or reduced withholding under IRC7

03

Income is not from U.S. sources

Foreign entity that assumes primary withholding responsibility

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
05
U.S. branch—treated as U.S. person10
06
07

U.S. branch—not treated as U.S. person11
U.S. branch—ECI presumption applied

08

Partnership other than withholding foreign partnership,
publicly traded partnership, or partnership QDD

09
10
11
12
13
14
15
16

Withholding foreign partnership
Trust other than withholding foreign trust
Withholding foreign trust
Qualified intermediary
Qualified securities lender—qualified intermediary
Qualified securities lender—other
Corporation
Individual
See back of Copy D for additional codes

2 If compensation that would otherwise 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, publicly traded partnership, or partnership QDD).

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.
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.
9 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.

10 This code can be used by a territory FI that is treated as a U.S. person.
11 This code can be used by a territory FI that is not treated as a U.S. person.

DRAFT — DO NOT FILE

DRAFT — DO NOT FILE

Explanation of Codes (continued)

TREASURY/IRS AND OMB USE ONLY DRAFT
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.

Department of the Treasury
Internal Revenue Service

UNIQUE FORM IDENTIFIER

1 Income 2 Gross income 3 Chapter indicator. Enter “3” or “4”
code
3a Exemption code
4a Exemption code
3b Tax rate

.

4b Tax rate

.

AMENDED

2027

OMB No. 1545-0096

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

AMENDMENT NO.

13i Recipient’s U.S. TIN, if any

13j Ch. 3 status code

13l Recipient’s GIIN

13m Recipient’s FTIN, if any

13k Ch. 4 status code

5 Withholding allowance
6 Net income
7a Federal tax withheld

13n LOB code

7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied. See instructions . . . . . .

13p Recipient’s date of birth (YYYYMMDD)

7c Check if withholding occurred in subsequent year with respect to a
partnership interest . . . . . . . . . . . . .

.

7d Check if you are a qualified intermediary, withholding foreign
partnership, or withholding foreign trust revising its reporting on Form
1042-S to report to a specific recipient . . . . . . . . .

14a Primary withholding agent’s name (if applicable)
14b Primary withholding agent’s EIN

8 Tax withheld by other agents
9 Overwithheld tax repaid to recipient pursuant
to adjustment procedures (see instructions)

(

10 Total withholding credit
(combine boxes 7a, 8, and 9)

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

15 Check if pro-rata basis reporting
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

15e Intermediary or flow-through entity’s GIIN

12b Ch. 3 status code
12c Ch. 4 status code

12d Withholding agent’s name

15f Country code

12e Withholding agent’s global intermediary identification number (GIIN)

15h Address (number and street)

12f Country code

15i Room or suite no.

15j City or town

12h Address (number and street)

15k State or province

15l Country

12i Room or suite no.

12j City or town

16a Payer’s name

12k State or province

12l Country

12g FTIN, if any

15g FTIN, if any

12m ZIP or foreign postal code

16c Payer’s GIIN

13b Recipient’s country code

17a State income tax withheld

15m ZIP or foreign postal code
16b Payer’s TIN
16d Ch. 3 status code
16e Ch. 4 status code

13a Recipient’s name

17b Payer’s state tax no.

17c Name of state

13c Address (number and street)
13d Apt. no.

13e City or town

13f State or province

13g Country

13h ZIP or foreign postal code
Form 1042-S (2027)

DRAFT — DO NOT FILE

DRAFT — DO NOT FILE

13o Recipient’s account number

TREASURY/IRS AND OMB USE ONLY DRAFT
17
18
19
20
21
22
23
24
25
26
35
36
37
38
39
40

Estate
Private foundation
International organization
Tax-exempt organization (section 501(c) entities)
Unknown recipient
Artist or athlete
Pension
Foreign central bank of issue
Nonqualified intermediary
Hybrid entity making treaty claim
Qualified derivatives dealer
Foreign government—integral part
Foreign government—controlled entity
Publicly traded partnership
Disclosing qualified intermediary
Partnership QDD12

41

U.S. Government entity or tax-exempt entity (other than
section 501(c) entities)13

Pooled Reporting Codes14
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
11

Certified deemed-compliant FFI—FFI with low value
accounts

12
13

Certified deemed-compliant FFI—nonregistering local bank
Certified deemed-compliant FFI—sponsored entity

14

Certified deemed-compliant FFI—investment entity that
does not maintain financial accounts

15
16
17

Nonparticipating FFI
Owner-documented FFI
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

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 account15

40
Passive NFFE reported by FFI16
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—generaI17
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

09

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

10
11
12

Discretionary determination
Other
No LOB article in treaty

12 Status code 40 should only be used for the partnership’s allocations to its partners with respect to its (or its branch’s) QDD’s activities. The partnership should report

all other allocations with respect to its partners using status code 8, 9, or 38, as applicable. When the partnership is transacting in its QDD capacity, it should use
status code 35.

13 This includes a college, a university, or another U.S. entity exempt from tax under an Internal Revenue Code section other than section 501(c). This code is only

applicable for reporting the chapter 3 status of a withholding agent (box 12b).

14 Codes 27 through 32 should only be used by a QI, QSL, WP, or WT. A QI acting as a QDD may use only code 27 or 28.
15 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.

16 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 FFI in boxes 15d and 15e.

17 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.

DRAFT — DO NOT FILE

DRAFT — DO NOT FILE

Explanation of Codes (continued)