Fillable Printable Form 1042-S
Fillable Printable Form 1042-S
Form 1042-S
Form 1042-S
Department of the Treasury
Internal Revenue Service
Foreign Person’s U.S. Source Income Subject to Withholding
▶
Information about Form 1042-S and its separate instructions is at www.irs.gov/form1042s.
2017
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
OMB No. 1545-0096
Copy A for
Internal Revenue Service
1 Income
code
2 Gross income
3 Chapter indicator. Enter “3” or “4”
3a Exemption code
3b Tax rate .
4a
Exemption code
4b Tax rate .
5 Withholding allowance
6 Net income
7a Federal tax withheld
7b
Check if tax not deposited with
IRS pursuant to escrow procedure
8 Tax withheld by other agents
9 Tax paid by withholding agent
10 Total withholding credit
11 Amount repaid to recipient
12a Withholding agent's EIN
12b
Ch. 3 status code
12c
Ch. 4 status code
12d Withholding agent's name
12e Withholding agent's Global Intermediary Identification Number (GIIN)
12f Country code 12g Foreign taxpayer identification number, if any
12h Address (number and street)
12i City or town, state or province, country, ZIP or foreign postal code
13a Recipient's name 13b Recipient's country code
13c
Address (number and street)
13d City or town, state or province, country, ZIP or foreign postal code
13e Recipient's U.S. TIN, if any
13f Ch. 3 status code
13g Ch. 4 status code
13h
Recipient's GIIN
13i
Recipient's foreign tax identification
number, if any
13j
LOB code
13k Recipient's account number 13l Recipient's date of birth
14a
Primary Withholding Agent's Name (if applicable)
14b Primary Withholding Agent's EIN
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
15d
Intermediary or flow-through entity's name
15e
Intermediary or flow-through entity's GIIN
15f Country code 15g Foreign tax identification number, if any
15h Address (number and street)
15i City or town, state or province, country, ZIP or foreign postal code
16a Payer's name 16b Payer's TIN
16c Payer's GIIN
16d
Ch. 3 status code
16e
Ch. 4 status code
17a State income tax withheld 17b Payer's state tax no. 17c Name of state
For Privacy Act and Paperwork Reduction Act Notice, see instructions.
Cat. No. 11386R
Form 1042-S (2017)
Form 1042-S
Department of the Treasury
Internal Revenue Service
Foreign Person’s U.S. Source Income Subject to Withholding
▶
Information about Form 1042-S and its separate instructions is at www.irs.gov/form1042s.
2017
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
OMB No. 1545-0096
Copy B
for Recipient
1 Income
code
2 Gross income
3 Chapter indicator. Enter “3” or “4”
3a Exemption code
3b Tax rate .
4a
Exemption code
4b Tax rate .
5 Withholding allowance
6 Net income
7a Federal tax withheld
7b
Check if tax not deposited with
IRS pursuant to escrow procedure
8 Tax withheld by other agents
9 Tax paid by withholding agent
10 Total withholding credit
11 Amount repaid to recipient
12a Withholding agent's EIN
12b
Ch. 3 status code
12c
Ch. 4 status code
12d Withholding agent's name
12e Withholding agent's Global Intermediary Identification Number (GIIN)
12f Country code 12g Foreign taxpayer identification number, if any
12h Address (number and street)
12i City or town, state or province, country, ZIP or foreign postal code
13a Recipient's name 13b Recipient's country code
13c
Address (number and street)
13d City or town, state or province, country, ZIP or foreign postal code
13e Recipient's U.S. TIN, if any
13f Ch. 3 status code
13g Ch. 4 status code
13h
Recipient's GIIN
13i
Recipient's foreign tax identification
number, if any
13j
LOB code
13k Recipient's account number 13l Recipient's date of birth
14a
Primary Withholding Agent's Name (if applicable)
14b Primary Withholding Agent's EIN
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
15d
Intermediary or flow-through entity's name
15e
Intermediary or flow-through entity's GIIN
15f Country code 15g Foreign tax identification number, if any
15h Address (number and street)
15i City or town, state or province, country, ZIP or foreign postal code
16a Payer's name 16b Payer's TIN
16c Payer's GIIN
16d
Ch. 3 status code
16e
Ch. 4 status code
17a State income tax withheld 17b Payer's state tax no. 17c Name of state
(keep for your records)
Form 1042-S (2017)
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 IRS.gov, 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 Etats-
Unis, 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 Etats-
Unis 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 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 (o el Formulario
1040NR-EZ si les corresponde). 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
(oder wenn passend das Formblatt 1040NR-EZ) ein.
Einkommensteuererklärungen und Instruktionen können unter IRS.gov
und 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
Box 1. Income Code.
Code Types of Income
Interest
01
Interest paid by U.S. obligors—general
02
Interest paid on real property mortgages
03
Interest paid to controlling foreign corporations
04
Interest paid by foreign corporations
05
Interest on tax-free covenant bonds
22 Interest paid on deposit with a foreign branch of a domestic
corporation or partnership
29
Deposit Interest
30
Original issue discount (OID)
31
Short-term OID
33
Substitute payment—interest
51 Interest paid on certain actively traded or publicly offered
securities
1
54 Substitute payments—interest from certain actively traded
or publicly offered securities
1
06 Dividends paid by U.S. corporations—general
07 Dividends qualifying for direct dividend rate
08 Dividends paid by foreign corporations
Dividend
Dividend
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
securities
1
53
Substitute payments-dividends from certain actively traded or
publicly offered securities
1
Other
09 Capital gains
10 Industrial royalties
11 Motion picture or television copyright royalties
12 Other royalties (for example, copyright, software,
broadcasting, endorsement payments)
13 Royalties paid on certain publicly offered securities
1
14 Real property income and natural resources royalties
15 Pensions, annuities, alimony, and/or insurance premiums
16 Scholarship or fellowship grants
17 Compensation for independent personal services
2
18 Compensation for dependent personal services
2
19 Compensation for teaching
2
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
Department of the Treasury
Internal Revenue Service
Foreign Person’s U.S. Source Income Subject to Withholding
▶
Information about Form 1042-S and its separate instructions is at www.irs.gov/form1042s.
2017
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
OMB No. 1545-0096
Copy C for Recipient
Attach to any Federal tax return you file
1 Income
code
2 Gross income
3 Chapter indicator. Enter “3” or “4”
3a Exemption code
3b Tax rate .
4a
Exemption code
4b Tax rate .
5 Withholding allowance
6 Net income
7a Federal tax withheld
7b
Check if tax not deposited with
IRS pursuant to escrow procedure
8 Tax withheld by other agents
9 Tax paid by withholding agent
10 Total withholding credit
11 Amount repaid to recipient
12a Withholding agent's EIN
12b
Ch. 3 status code
12c
Ch. 4 status code
12d Withholding agent's name
12e Withholding agent's Global Intermediary Identification Number (GIIN)
12f Country code 12g Foreign taxpayer identification number, if any
12h Address (number and street)
12i City or town, state or province, country, ZIP or foreign postal code
13a Recipient's name 13b Recipient's country code
13c
Address (number and street)
13d City or town, state or province, country, ZIP or foreign postal code
13e Recipient's U.S. TIN, if any
13f Ch. 3 status code
13g Ch. 4 status code
13h
Recipient's GIIN
13i
Recipient's foreign tax identification
number, if any
13j
LOB code
13k Recipient's account number 13l Recipient's date of birth
14a
Primary Withholding Agent's Name (if applicable)
14b Primary Withholding Agent's EIN
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
15d
Intermediary or flow-through entity's name
15e
Intermediary or flow-through entity's GIIN
15f Country code 15g Foreign tax identification number, if any
15h Address (number and street)
15i City or town, state or province, country, ZIP or foreign postal code
16a Payer's name 16b Payer's TIN
16c Payer's GIIN
16d
Ch. 3 status code
16e
Ch. 4 status code
17a State income tax withheld 17b Payer's state tax no. 17c Name of state
Form 1042-S (2017)
Explanation of Codes (continued)
Other
20 Compensation during studying and training
2
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 Gambling winnings
3
32 Notional principal contract income
4
35 Substitute payment—other
36 Capital gains distributions
37 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 Earnings as an artist or athlete—no central withholding
agreement
5
43 Earnings as an artist or athlete—central withholding
agreement
5
44 Specified federal procurement payments
50 Income previously reported under escrow procedure
6
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
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
22 QDD that assumes primary withholding responsibility
Chapter 4
13 Grandfathered payment
14 Effectively connected income
15 Payee not subject to chapter 4 withholding
16 Excluded nonfinancial payment
17 Foreign Entity that assumes primary withholding
responsibility
18 U.S. Payees—of participating FFI or registered deemed-
compliant FFI
19 Exempt from withholding under IGA
7
20 Dormant account
8
21 Other—payment not subject to chapter 4 withholding
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
Use only to report a U.S. reportable account or nonconsenting 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 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
Department of the Treasury
Internal Revenue Service
Foreign Person’s U.S. Source Income Subject to Withholding
▶
Information about Form 1042-S and its separate instructions is at www.irs.gov/form1042s.
2017
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
OMB No. 1545-0096
Copy D for Recipient
Attach to any state tax return you file
1 Income
code
2 Gross income
3 Chapter indicator. Enter “3” or “4”
3a Exemption code
3b Tax rate .
4a
Exemption code
4b Tax rate .
5 Withholding allowance
6 Net income
7a Federal tax withheld
7b
Check if tax not deposited with
IRS pursuant to escrow procedure
8 Tax withheld by other agents
9 Tax paid by withholding agent
10 Total withholding credit
11 Amount repaid to recipient
12a Withholding agent's EIN
12b
Ch. 3 status code
12c
Ch. 4 status code
12d Withholding agent's name
12e Withholding agent's Global Intermediary Identification Number (GIIN)
12f Country code 12g Foreign taxpayer identification number, if any
12h Address (number and street)
12i City or town, state or province, country, ZIP or foreign postal code
13a Recipient's name 13b Recipient's country code
13c
Address (number and street)
13d City or town, state or province, country, ZIP or foreign postal code
13e Recipient's U.S. TIN, if any
13f Ch. 3 status code
13g Ch. 4 status code
13h
Recipient's GIIN
13i
Recipient's foreign tax identification
number, if any
13j
LOB code
13k Recipient's account number 13l Recipient's date of birth
14a
Primary Withholding Agent's Name (if applicable)
14b Primary Withholding Agent's EIN
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
15d
Intermediary or flow-through entity's name
15e
Intermediary or flow-through entity's GIIN
15f Country code 15g Foreign tax identification number, if any
15h Address (number and street)
15i City or town, state or province, country, ZIP or foreign postal code
16a Payer's name 16b Payer's TIN
16c Payer's GIIN
16d
Ch. 3 status code
16e
Ch. 4 status code
17a State income tax withheld 17b Payer's state tax no. 17c Name of state
Form 1042-S (2017)
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 Codes
9
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
36 Qualifying dividend equivalent offsetting payments to U.S.
persons
37 Nonqualifying dividend equivalent payments to U.S.
persons—Undisclosed
38 Other qualifying dividend equivalent offsetting payments
(ECI)
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 Certified Deemed-Compliant FFI—Nonregistering Local
Bank
13 Certified Deemed-Compliant FFI—Sponsored Entity
14 Certified Deemed-Compliant FFI—Investment Advisor or
Investment Manager
15 Nonparticipating FFI
16 Owner-Documented FFI
19 Passive NFFE identifying Substantial U.S. Owners
20 Passive NFFE with no Substantial U.S. Owners
21 Publicly Traded NFFE or Affiliate of Publicly Traded NFFE
22 Active NFFE
23 Individual
24 Section 501(c) Entities
25 Excepted Territory NFFE
26 Excepted NFFE—Other
27 Exempt Beneficial Owner
28 Entity Wholly Owned by Exempt Beneficial Owners
29 Unknown Recipient
30 Recalcitrant Account Holder
31 Nonreporting IGA FFI
32 Direct reporting NFFE
33 U.S. reportable account
34 Nonconsenting U.S. account
35 Sponsored direct reporting NFFE
36 Excepted Inter-affiliate FFI
37 Undocumented Preexisting Obligation
38 U.S. Branch—ECI presumption applied
39 Account Holder of Excluded Financial Account
10
40 Passive NFFE reported by FFI
11
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—GeneraI
12
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
01 Individual
02 Government – contracting state/political subdivision/local
authority
03 Tax exempt pension trust/Pension fund
04 Tax exempt/Charitable organization
05 Publicly traded corporation
06 Subsidiary of publicly traded corporation
07 Company that meets the ownership and base erosion test
08 Company that meets the derivative benefits test
09 Company with an item of income that meets the active trade
or business test
10 Discretionary determination
11 Other
9
Codes 27 through 33 should only be used by a QI (including a QI acting as a QDD), QSL, WP, or WT. Codes 36 through 38 should only be used by a QI acting as a QDD.
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.
11
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.
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
Department of the Treasury
Internal Revenue Service
Foreign Person’s U.S. Source Income Subject to Withholding
▶
Information about Form 1042-S and its separate instructions is at www.irs.gov/form1042s.
2017
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
OMB No. 1545-0096
Copy E
for Withholding Agent
1 Income
code
2 Gross income
3 Chapter indicator. Enter “3” or “4”
3a Exemption code
3b Tax rate .
4a
Exemption code
4b Tax rate .
5 Withholding allowance
6 Net income
7a Federal tax withheld
7b
Check if tax not deposited with
IRS pursuant to escrow procedure
8 Tax withheld by other agents
9 Tax paid by withholding agent
10 Total withholding credit
11 Amount repaid to recipient
12a Withholding agent's EIN
12b
Ch. 3 status code
12c
Ch. 4 status code
12d Withholding agent's name
12e Withholding agent's Global Intermediary Identification Number (GIIN)
12f Country code 12g Foreign taxpayer identification number, if any
12h Address (number and street)
12i City or town, state or province, country, ZIP or foreign postal code
13a Recipient's name 13b Recipient's country code
13c
Address (number and street)
13d City or town, state or province, country, ZIP or foreign postal code
13e Recipient's U.S. TIN, if any
13f Ch. 3 status code
13g Ch. 4 status code
13h
Recipient's GIIN
13i
Recipient's foreign tax identification
number, if any
13j
LOB code
13k Recipient's account number 13l Recipient's date of birth
14a
Primary Withholding Agent's Name (if applicable)
14b Primary Withholding Agent's EIN
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
15d
Intermediary or flow-through entity's name
15e
Intermediary or flow-through entity's GIIN
15f Country code 15g Foreign tax identification number, if any
15h Address (number and street)
15i City or town, state or province, country, ZIP or foreign postal code
16a Payer's name 16b Payer's TIN
16c Payer's GIIN
16d
Ch. 3 status code
16e
Ch. 4 status code
17a State income tax withheld 17b Payer's state tax no. 17c Name of state
Form 1042-S (2017)
