Form 13930 - Application For Central Withholding Agreement Page 4
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6Department of the Treasury - Internal Revenue Service
13930
OMB Number
Form
Application for Central Withholding Agreement
1545-2102
(December 2012)
1. Athlete/Entertainer
AE-ID
Date received
(nonresident alien)
(IRS Use Only)
(IRS Use Only)
a. Legal Name
c. U.S. Taxpayer ID (SSN)
(last, first, middle initial)
b. Address
d. Date of birth
e. Country of residence
g. Applying as
f. Country of citizenship
Athlete
Entertainer
h. Group name
i. Percentage share of net income
(if applicable)
k. Marital status
j. Stage name
Married
Single
l. Operating as business
Business name
(LLC, corporation, partnership)
U.S. Taxpayer ID of Business
Country where business established
Date business started
Employer Identification Number (EIN) where 1042 deposits are being made
2. Withholding Agent
WHA-ID
CWA-ID
(IRS Use Only)
(IRS Use Only)
a. Name
d. U.S. Taxpayer ID (EIN/SSN)
b. Firm
e. Voice phone number
c. Address
f. Fax phone number
g. All CWA Deposits are required to be made using EFTPS. Are you currently enrolled in EFTPS
Yes
No
h. I am acting as
Promoter
Agent
Venue
Other
I declare that I have examined under penalties of perjury and to the best of my knowledge and belief, the statements are true, correct,
and complete.
Signature
Date
*Must be signed by each NRA on application unless signed by POA with authority under Form 2848
3. Contact Person: The valid Form 2848 or Form 8821 holder will be contacted for additional information if necessary. If utilizing Form
8821 please identify all individuals covered by the Form 8821
a. Name
b. Firm
c. Address
d. Voice phone number
e. Fax phone number
13930
Catalog Number 50991Q
Form
(Rev. 12-2012)
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