Form 1042-S

Foreign Person's U.S. Source Income Subject to Withholding

U.S.-source income paid to foreign persons, with chapter 3/4 status and withholding.

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Issuer / payer

The business or person that paid and is filing this return. Enter either a business name or an individual name.

Foreign entityIssuer TIN *TIN type *Business name controlFirst 4 significant characters of the business name.Business nameBusiness name (line 2)Individual first nameIndividual middle nameIndividual last nameForeign addressCheck to enter a non-US address (country + province + postal code).Address line 1 *Address line 2City *State (US address)Required for a US address.ZIP code (US address)Province / region (foreign)Country code (foreign)Two-letter ISO country code for a foreign address.Postal code (foreign)Phone number

Recipient (foreign person)

The foreign person or entity that received the U.S.-source income.

Business name controlBusiness nameBusiness name (line 2)Individual first nameIndividual middle nameIndividual last nameAdditional recipient13bCountry codeForeign addressCheck to enter a non-US address (country + province + postal code).Address line 1 *Address line 2City *State (US address)Required for a US address.ZIP code (US address)Province / region (foreign)Country code (foreign)Two-letter ISO country code for a foreign address.Postal code (foreign)13eRecipient TINTIN type13fChapter 3 status code13gChapter 4 status code13hRecipient GIIN13iForeign TIN13jLimitation on benefits (LOB) code13kAccount number13lDate of birth

Filing details

Tax year *Unique form identifier *A number you assign to uniquely identify this 1042-S within the submission.AmendedAmendment number15Pro-rata basis reporting

Income & withholding

1Income code *2Gross income *3Chapter indicator *5Withholding allowance6Net income7aFederal tax withheld *7bTax not deposited under escrow procedure7cWithholding occurred in subsequent year (partnership interest)7dQI/WP/WT revising reporting8Tax withheld by other agents *9Overwithheld tax repaid to recipient10Total withholding credit *11Tax paid by withholding agent

Chapter 3 (boxes 3a–3b)

Chapter 4 (boxes 4a–4b)

Primary withholding agent (box 14)

Intermediary or flow-through entity (box 15)

Payer (box 16)

State tax

State tax #1

State *State tax withheldState ID number

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