Free 2009 Form 1042-S - Federal

Form

1042-S

Department of the Treasury Internal Revenue Service

Foreign Person's U.S. Source Income Subject to Withholding
AMENDED
3 Withholding allowances 4 Net income 5 Tax rate 6 Exemption code

2009
7 Federal tax withheld

OMB No. 1545-0096

PRO-RATA BASIS REPORTING

Copy A for Internal Revenue Service

1 Income 2 Gross income code

8 Withholding by other agents 9 Total withholding credit

10 Amount repaid to recipient 11 Withholding agent's EIN EIN 12a WITHHOLDING AGENT'S name 12b Address (number and street) 12c Additional address line (room or suite no.) 12d City or town, province or state, country, ZIP or foreign postal code 13a RECIPIENT'S name 13c Address (number and street) 13d Additional address line (room or suite no.) 13e City or town, province or state, country, ZIP or foreign postal code QI-EIN

14 15 17

Recipient's U.S. TIN, if any SSN or ITIN EIN Recipient's foreign tax identifying number, if any NQI's/FLOW-THROUGH ENTITY'S name QI-EIN 16 Country code 18 Country code

19a NQI's/Entity's address (number and street) 19b Additional address line (room or suite no.) 19c City or town, province or state, country, ZIP or foreign postal code NQI's/Entity's U.S. TIN, if any PAYER'S name and TIN (if different from withholding agent's) Recipient account number (optional) State income tax withheld 24 Payer's state tax no. 25 Name of state
Cat. No. 11386R Form

13b Recipient code 20 21 22 23

For Privacy Act and Paperwork Reduction Act Notice, see page 16 of the separate instructions.

1042-S

(2009)

Form

1042-S

Department of the Treasury Internal Revenue Service

Foreign Person's U.S. Source Income Subject to Withholding
AMENDED
3 Withholding allowances 4 Net income 5 Tax rate 6 Exemption code

2009
7 Federal tax withheld 9 Total withholding credit

OMB No. 1545-0096

Copy B
for Recipient

PRO-RATA BASIS REPORTING
8 Withholding by other agents

1 Income 2 Gross income code

10 Amount repaid to recipient 11 Withholding agent's EIN EIN 12a WITHHOLDING AGENT'S name 12b Address (number and street) 12c Additional address line (room or suite no.) 12d City or town, province or state, country, ZIP or foreign postal code 13a RECIPIENT'S name 13c Address (number and street) 13d Additional address line (room or suite no.) 13e City or town, province or state, country, ZIP or foreign postal code QI-EIN

14 15 17

Recipient's U.S. TIN, if any SSN or ITIN EIN Recipient's foreign tax identifying number, if any NQI's/FLOW-THROUGH ENTITY'S name QI-EIN 16 Country code 18 Country code

19a NQI's/Entity's address (number and street) 19b Additional address line (room or suite no.) 19c City or town, province or state, country, ZIP or foreign postal code NQI's/Entity's U.S. TIN, if any PAYER'S name and TIN (if different from withholding agent's) Recipient account number (optional) State income tax withheld 24 Payer's state tax no. 25 Name of state
Cat. No. 11386R Form

13b Recipient code 20 21 22 23

For Privacy Act and Paperwork Reduction Act Notice, see page 16 of the separate instructions.

1042-S

(2009)

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 a 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 Etats-Unis, doit soumettre aux Etats-Unis, une déclaration d'impôt sur le revenu. Cependant aucune déclaration d'impôt sur le revenu n'est exigée d'un étranger non-résident, d'un organisme fidéicommissaire étrange 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, de leur montant. (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 si éligible).) On peut se procurer formulaires de déclarations d'impôts et instructions dans toutes les Ambassades et tous les Consulats des Etats-Unis. L'on peut également s'adresser pour tous renseignements a: 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 retencion del impuesto de los Estados Unidos en la fuente. (Las sociedades anónimas envian la Forma 1120-F; todos los demás contribuyentes envian la Forma 1040NR (o la Forma 1040NR-EZ si le corresponde).) Se podrán obtener formas 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

Foreign Person's U.S. Source Income Subject to Withholding
AMENDED
3 Withholding allowances 4 Net income 5 Tax rate 6 Exemption code

2009
7 Federal tax withheld

OMB No. 1545-0096

Copy C

for Recipient

PRO-RATA BASIS REPORTING

Attach to any Federal tax return you file

1 Income 2 Gross income code

8 Withholding by other agents 9 Total withholding credit

10 Amount repaid to recipient 11 Withholding agent's EIN EIN 12a WITHHOLDING AGENT'S name 12b Address (number and street) 12c Additional address line (room or suite no.) 12d City or town, province or state, country, ZIP or foreign postal code 13a RECIPIENT'S name 13c Address (number and street) 13d Additional address line (room or suite no.) 13e City or town, province or state, country, ZIP or foreign postal code QI-EIN

14 15 17

Recipient's U.S. TIN, if any SSN or ITIN EIN Recipient's foreign tax identifying number, if any NQI's/FLOW-THROUGH ENTITY'S name QI-EIN 16 Country code 18 Country code

19a NQI's/Entity's address (number and street) 19b Additional address line (room or suite no.) 19c City or town, province or state, country, ZIP or foreign postal code NQI's/Entity's U.S. TIN, if any PAYER'S name and TIN (if different from withholding agent's) Recipient account number (optional) State income tax withheld 24 Payer's state tax no. 25 Name of state
Cat. No. 11386R Form

13b Recipient code 20 21 22 23

For Privacy Act and Paperwork Reduction Act Notice, see page 16 of the separate instructions.

1042-S

(2009)

Explanation of Codes
Box 1. Income code. Code Types of Income 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 29 Deposit interest 30 Original issue discount (OID) 31 Short-term OID 33 Substitute payment--interest Dividend Interest 06 07 08 34 09 10 11 12 13 14 15 16 17 18 19 20 24 25 26 27 28 32 35 36 37 50
1 2

Dividends paid by U.S. corporations--general Dividends qualifying for direct dividend rate Dividends paid by foreign corporations Substitute payment--dividends Capital gains Industrial royalties Motion picture or television copyright royalties Other royalties (for example, copyright, recording, publishing) Real property income and natural resources royalties Pensions, annuities, alimony, and/or insurance premiums Scholarship or fellowship grants Compensation for independent personal services1 Compensation for dependent personal services1 Compensation for teaching1 Compensation during studying and training1 Earnings as an artist or athlete2 Real estate investment trust (REIT) 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 6 Gambling winnings 3 Notional principal contract income Substitute payment--other Capital gains distributions Return of capital Other income

Box 6. Exemption code (applies if the tax rate entered in box 5 is 00.00). Code Authority for Exemption 01 Income effectively connected with a U.S. trade or business 02 Exempt under an Internal Revenue Code section (income other than portfolio interest) 03 Income is not from U.S. sources4 04 Exempt under tax treaty 05 Portfolio interest exempt under an Internal Revenue Code section 06 Qualified intermediary that assumes primary withholding responsibility 07 Withholding foreign partnership or withholding foreign trust 08 U.S. branch treated as a U.S. person 09 Qualified intermediary represents income is exempt Box 13b. Recipient code. Code Type of Recipient 01 Individual2 02 Corporation2 03 Partnership other than withholding foreign partnership2 04 Withholding foreign partnership or withholding foreign trust 05 Trust 06 Government or international organization 07 Tax-exempt organization (IRC section 501(a)) 08 Private foundation 09 Artist or athlete2 10 Estate 11 U.S. branch treated as U.S. person 12 Qualified intermediary 13 Private arrangement intermediary withholding rate pool--general5 14 Private arrangement intermediary withholding rate pool-- exempt organizations5 15 Qualified intermediary withholding rate pool--general5 16 Qualified intermediary withholding rate pool--exempt organizations5 17 Authorized foreign agent 18 Public pension fund 20 Unknown recipient

If compensation that otherwise would be covered under Income Codes 16­19 is directly attributable to the recipient's occupation as an artist or athlete, use Income Code 20 instead. If Income Code 20 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). 3 Use appropriate Interest Income Code for embedded interest in a notional principal contract. 4 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. 5 May be used only by a qualified intermediary. 6 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.

Other

Form

1042-S

Department of the Treasury Internal Revenue Service

Foreign Person's U.S. Source Income Subject to Withholding
AMENDED
3 Withholding allowances 4 Net income 5 Tax rate 6 Exemption code

2009
7 Federal tax withheld

OMB No. 1545-0096

Copy D

for Recipient

PRO-RATA BASIS REPORTING

Attach to any state tax return you file

1 Income 2 Gross income code

8 Withholding by other agents 9 Total withholding credit

10 Amount repaid to recipient 11 Withholding agent's EIN EIN 12a WITHHOLDING AGENT'S name 12b Address (number and street) 12c Additional address line (room or suite no.) 12d City or town, province or state, country, ZIP or foreign postal code 13a RECIPIENT'S name 13c Address (number and street) 13d Additional address line (room or suite no.) 13e City or town, province or state, country, ZIP or foreign postal code QI-EIN

14 15 17

Recipient's U.S. TIN, if any SSN or ITIN EIN Recipient's foreign tax identifying number, if any NQI's/FLOW-THROUGH ENTITY'S name QI-EIN 16 Country code 18 Country code

19a NQI's/Entity's address (number and street) 19b Additional address line (room or suite no.) 19c City or town, province or state, country, ZIP or foreign postal code NQI's/Entity's U.S. TIN, if any PAYER'S name and TIN (if different from withholding agent's) Recipient account number (optional) State income tax withheld 24 Payer's state tax no. 25 Name of state
Cat. No. 11386R Form

13b Recipient code 20 21 22 23

For Privacy Act and Paperwork Reduction Act Notice, see page 16 of the separate instructions.

1042-S

(2009)

Form

1042-S

Department of the Treasury Internal Revenue Service

Foreign Person's U.S. Source Income Subject to Withholding
AMENDED
3 Withholding allowances 4 Net income 5 Tax rate 6 Exemption code

2009
7 Federal tax withheld 9 Total withholding credit

OMB No. 1545-0096

Copy E
for Withholding Agent

PRO-RATA BASIS REPORTING

1 Income 2 Gross income code

8 Withholding by other agents

10 Amount repaid to recipient 11 Withholding agent's EIN EIN 12a WITHHOLDING AGENT'S name 12b Address (number and street) 12c Additional address line (room or suite no.) 12d City or town, province or state, country, ZIP or foreign postal code 13a RECIPIENT'S name 13c Address (number and street) 13d Additional address line (room or suite no.) 13e City or town, province or state, country, ZIP or foreign postal code QI-EIN

14 15 17

Recipient's U.S. TIN, if any SSN or ITIN EIN Recipient's foreign tax identifying number, if any NQI's/FLOW-THROUGH ENTITY'S name QI-EIN 16 Country code 18 Country code

19a NQI's/Entity's address (number and street) 19b Additional address line (room or suite no.) 19c City or town, province or state, country, ZIP or foreign postal code NQI's/Entity's U.S. TIN, if any PAYER'S name and TIN (if different from withholding agent's) Recipient account number (optional) State income tax withheld 24 Payer's state tax no. 25 Name of state
Cat. No. 11386R Form

13b Recipient code 20 21 22 23

For Privacy Act and Paperwork Reduction Act Notice, see page 16 of the separate instructions.

1042-S

(2009)