Form 1042-S Foreign Persons U.S. Source Income Subject to Withholdin

Form

1042-S

Department of the Treasury
Internal Revenue Service
1 Income
2 Gross income
code

2012

Foreign Person’s U.S. Source Income
Subject to Withholding
AMENDED

3 Withholding
allowances

PRO-RATA BASIS REPORTING

4 Net income

5 Tax rate
6 Exemption code

.

OMB No. 1545-0096

Copy A for
Internal Revenue Service

7 Federal tax withheld
8 Withholding by other agents
9 Total withholding credit

10

Amount repaid to recipient

14

Recipient’s U.S. TIN, if any ▶

11

Withholding agent’s EIN ▶

15

SSN or ITIN
EIN
QI-EIN
Recipient’s foreign tax identifying number, if any
16 Country code

EIN
QI-EIN
12a WITHHOLDING AGENT’S name

17

NQI’s/FLOW-THROUGH ENTITY’S name

12b Address (number and street)

19a NQI’s/Entity’s address (number and street)

12c Additional address line (room or suite no.)

19b Additional address line (room or suite no.)

12d City or town, province or state, country, ZIP or foreign postal code

19c City or town, province or state, country, ZIP or foreign postal code

13a RECIPIENT’S name

13b Recipient code 20

18 Country code

NQI’s/Entity’s U.S. TIN, if any ▶

13c Address (number and street)

21

PAYER’S name and TIN (if different from withholding agent’s)

13d Additional address line (room or suite no.)

22

Recipient account number (optional)

13e City or town, province or state, country, ZIP or foreign postal code

23

State income tax withheld 24 Payer’s state tax no. 25 Name of state

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

Cat. No. 11386R

Form 1042-S (2012)

Form

1042-S

Department of the Treasury
Internal Revenue Service
1 Income
2 Gross income
code

2012

Foreign Person’s U.S. Source Income
Subject to Withholding
AMENDED

3 Withholding
allowances

PRO-RATA BASIS REPORTING

4 Net income

5 Tax rate
6 Exemption code

.

OMB No. 1545-0096

Copy B

for Recipient

7 Federal tax withheld
8 Withholding by other agents
9 Total withholding credit

10

Amount repaid to recipient

14

Recipient’s U.S. TIN, if any ▶

11

Withholding agent’s EIN ▶

15

SSN or ITIN
EIN
QI-EIN
Recipient’s foreign tax identifying number, if any
16 Country code

EIN
QI-EIN
12a WITHHOLDING AGENT’S name

17

NQI’s/FLOW-THROUGH ENTITY’S name

12b Address (number and street)

19a NQI’s/Entity’s address (number and street)

12c Additional address line (room or suite no.)

19b Additional address line (room or suite no.)

12d City or town, province or state, country, ZIP or foreign postal code

19c City or town, province or state, country, ZIP or foreign postal code

13a RECIPIENT’S name

13b Recipient code 20

18 Country code

NQI’s/Entity’s U.S. TIN, if any ▶

13c Address (number and street)

21

PAYER’S name and TIN (if different from withholding agent’s)

13d Additional address line (room or suite no.)

22

Recipient account number (optional)

13e City or town, province or state, country, ZIP or foreign postal code

23

State income tax withheld 24 Payer’s state tax no. 25 Name of state

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

Cat. No. 11386R

Form 1042-S (2012)

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 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 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 (ou 1040NR-EZ s'ils
en remplissent les conditions). On peut se procurer les formulaires de
déclarations d’impôts et les instructions y afférentes 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 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 1040NREZ si le corresponde). Se podrá obtener formularios e instrucciones
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 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

Form

1042-S

Department of the Treasury
Internal Revenue Service
1 Income
2 Gross income
code

2012

Foreign Person’s U.S. Source Income
Subject to Withholding
AMENDED

3 Withholding
allowances

PRO-RATA BASIS REPORTING

4 Net income

5 Tax rate
6 Exemption code

.

OMB No. 1545-0096

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

7 Federal tax withheld
8 Withholding by other agents
9 Total withholding credit

10

Amount repaid to recipient

14

Recipient’s U.S. TIN, if any ▶

11

Withholding agent’s EIN ▶

15

SSN or ITIN
EIN
QI-EIN
Recipient’s foreign tax identifying number, if any
16 Country code

EIN
QI-EIN
12a WITHHOLDING AGENT’S name

17

NQI’s/FLOW-THROUGH ENTITY’S name

12b Address (number and street)

19a NQI’s/Entity’s address (number and street)

12c Additional address line (room or suite no.)

19b Additional address line (room or suite no.)

12d City or town, province or state, country, ZIP or foreign postal code

19c City or town, province or state, country, ZIP or foreign postal code

13a RECIPIENT’S name

13b Recipient code 20

18 Country code

NQI’s/Entity’s U.S. TIN, if any ▶

13c Address (number and street)

21

PAYER’S name and TIN (if different from withholding agent’s)

13d Additional address line (room or suite no.)

22

Recipient account number (optional)

13e City or town, province or state, country, ZIP or foreign postal code

23

State income tax withheld 24 Payer’s state tax no. 25 Name of state

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

Cat. No. 11386R

Form 1042-S (2012)

Explanation of Codes
Box 1. Income code.

Other

Dividend

Types of Income

14

Pensions, annuities, alimony, and/or insurance premiums

15

Scholarship or fellowship grants

01

Interest paid by U.S. obligors—general

16

Compensation for independent personal services1

02

Interest paid on real property mortgages

17

Compensation for dependent personal services1

03

Interest paid to controlling foreign corporations

18

Compensation for teaching1

04

Interest paid by foreign corporations

19

Compensation during studying and training1

05

Interest on tax-free covenant bonds

24

Real estate investment trust (REIT) distributions of capital gains

29

Deposit interest

30

Original issue discount (OID)

25
26

Trust distributions subject to IRC section 1445
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 winnings2

32

Notional principal contract income3

35

Substitute payment—other

36

Capital gains distributions

31

Short-term OID

33

Substitute payment—interest

06

Dividends paid by U.S. corporations—general

07

Dividends qualifying for direct dividend rate

08

Dividends paid by foreign corporations

34
40

Substitute payment—dividends
Other U.S. source dividend equivalents under IRC section 871(m)
(formerly 871(l))

Other

Interest

Code

37

Return of capital

38

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

09

Capital gains

39

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

10

Industrial royalties

41

Guarantee of indebtedness

11

Motion picture or television copyright royalties

42

Earnings as an artist or athlete—no central withholding agreement4

12

Other royalties (for example, copyright, recording, publishing)

43

Earnings as an artist or athlete—central withholding agreement4

13

Real property income and natural resources royalties

50

Other income
See back of Copy D for additional codes

1 If

compensation that otherwise would be covered under Income Codes 16 through 19 is directly attributable to the recipient’s occupation as an artist or athlete, use Income Code 42 or 43 instead.

2 Subject
3 Use

to 30% withholding rate unless the recipient is from one of the treaty countries listed under Gambling winnings (Income Code 28) in Pub. 515.

appropriate Interest Income Code for embedded interest in a notional principal contract.
4 If Income Code 42 or 43 is used, Recipient Code 09 (artist or athlete) should be used instead of Recipient Code 01 (individual), 02 (corporation), or 03 (partnership other than withholding foreign
partnership).

Form

1042-S

Department of the Treasury
Internal Revenue Service
1 Income
2 Gross income
code

2012

Foreign Person’s U.S. Source Income
Subject to Withholding
AMENDED

3 Withholding
allowances

PRO-RATA BASIS REPORTING

4 Net income

5 Tax rate
6 Exemption code

.

OMB No. 1545-0096

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

7 Federal tax withheld
8 Withholding by other agents
9 Total withholding credit

10

Amount repaid to recipient

14

Recipient’s U.S. TIN, if any ▶

11

Withholding agent’s EIN ▶

15

SSN or ITIN
EIN
QI-EIN
Recipient’s foreign tax identifying number, if any
16 Country code

EIN
QI-EIN
12a WITHHOLDING AGENT’S name

17

NQI’s/FLOW-THROUGH ENTITY’S name

12b Address (number and street)

19a NQI’s/Entity’s address (number and street)

12c Additional address line (room or suite no.)

19b Additional address line (room or suite no.)

12d City or town, province or state, country, ZIP or foreign postal code

19c City or town, province or state, country, ZIP or foreign postal code

13a RECIPIENT’S name

13b Recipient code 20

18 Country code

NQI’s/Entity’s U.S. TIN, if any ▶

13c Address (number and street)

21

PAYER’S name and TIN (if different from withholding agent’s)

13d Additional address line (room or suite no.)

22

Recipient account number (optional)

13e City or town, province or state, country, ZIP or foreign postal code

23

State income tax withheld 24 Payer’s state tax no. 25 Name of state

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

Cat. No. 11386R

Form 1042-S (2012)

Explanation of Codes (continued)
Box 6. Exemption code (applies if the tax rate entered in box 5 is 00.00).
Code

Authority for Exemption

Box 13b. Recipient code.
04 Withholding foreign partnership or withholding foreign trust

01 Income effectively connected with a U.S. trade or business

05 Trust

02 Exempt under an Internal Revenue Code section (income other than
portfolio interest)

06 Government or international organization

03 Income is not from U.S. sources1

08 Private foundation

04 Exempt under tax treaty

09 Artist or athlete2

05 Portfolio interest exempt under an Internal Revenue Code section

10 Estate

06 Qualified intermediary that assumes primary withholding responsibility

11 U.S. branch treated as U.S. person

07 Withholding foreign partnership or withholding foreign trust

12 Qualified intermediary

08 U.S. branch treated as a U.S. person

13 Private arrangement intermediary withholding rate pool—general3

09 Qualified intermediary represents income is exempt

14 Private arrangement intermediary withholding rate pool—
exempt organizations3

10 Qualified securities lender that assumes primary withholding
responsibility for substitute dividends

15 Qualified intermediary withholding rate pool—general3
16 Qualified intermediary withholding rate pool—exempt organizations3

Box 13b. Recipient code.
Code

07 Tax-exempt organization (IRC section 501(a))

Type of Recipient

17 Authorized foreign agent

01 Individual2

18 Public pension fund

02 Corporation2

20 Unknown recipient

03 Partnership other than withholding foreign partnership2

21 Qualified securities lender—qualified intermediary
22 Qualified securities lender—other

1 Non-U.S.

source income received by a nonresident alien is not subject to U.S. tax. Use Exemption Code 03 when entering an amount for information reporting purposes only.
Income Code 42 or 43 is used, Recipient Code 09 (artist or athlete) should be used instead of Recipient Code 01 (individual), 02 (corporation), or 03 (partnership other than withholding foreign
partnership).

2 If

3 May

be used only by a qualified intermediary.

Form

1042-S

Department of the Treasury
Internal Revenue Service
1 Income
2 Gross income
code

2012

Foreign Person’s U.S. Source Income
Subject to Withholding
AMENDED

3 Withholding
allowances

PRO-RATA BASIS REPORTING

4 Net income

5 Tax rate
6 Exemption code

.

OMB No. 1545-0096

Copy E

for Withholding Agent

7 Federal tax withheld
8 Withholding by other agents
9 Total withholding credit

10

Amount repaid to recipient

14

Recipient’s U.S. TIN, if any ▶

11

Withholding agent’s EIN ▶

15

SSN or ITIN
EIN
QI-EIN
Recipient’s foreign tax identifying number, if any
16 Country code

EIN
QI-EIN
12a WITHHOLDING AGENT’S name

17

NQI’s/FLOW-THROUGH ENTITY’S name

12b Address (number and street)

19a NQI’s/Entity’s address (number and street)

12c Additional address line (room or suite no.)

19b Additional address line (room or suite no.)

12d City or town, province or state, country, ZIP or foreign postal code

19c City or town, province or state, country, ZIP or foreign postal code

13a RECIPIENT’S name

13b Recipient code 20

18 Country code

NQI’s/Entity’s U.S. TIN, if any ▶

13c Address (number and street)

21

PAYER’S name and TIN (if different from withholding agent’s)

13d Additional address line (room or suite no.)

22

Recipient account number (optional)

13e City or town, province or state, country, ZIP or foreign postal code

23

State income tax withheld 24 Payer’s state tax no. 25 Name of state

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

Cat. No. 11386R

Form 1042-S (2012)