Form 1042 - Annual Withholding Tax Return For U.s. Source Income Of Foreign Persons - 2017

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1042
Annual Withholding Tax Return for U.S. Source
OMB No. 1545-0096
2017
Income of Foreign Persons
Form
Department of the Treasury
Go to for instructions and the latest information.
▶
Internal Revenue Service
If this is an amended return, check here .
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For IRS Use Only
Name of withholding agent
Employer identification number
CC
FD
Ch. 3 Status Code
Ch. 4 Status Code
RD
FF
Number, street, and room or suite no. (if a P.O. box, see instructions)
CAF
FP
CR
I
City or town, state or province, country, and ZIP or foreign postal code
EDC
SIC
If you do not expect to file this return in the future, check here
Enter date final income paid
▶
▶
Section 1
Record of Federal Tax Liability (Do not show federal tax deposits here)
Tax liability for period
Tax liability for period
Tax liability for period
Line
Period
(including any taxes assumed
Line
Period
(including any taxes assumed
Line
Period
(including any taxes assumed
ending
on Form(s) 1000)
ending
on Form(s) 1000)
ending
on Form(s) 1000)
No.
No.
No.
1
21
41
7
7
7
2
15
22
15
42
15
Jan.
May
Sept.
3
22
23
22
43
22
4
24
44
31
31
30
5 Jan. total
25 May total
45 Sept. total
6
7
26
7
46
7
7
27
47
15
15
15
Feb.
June
Oct.
8
22
28
22
48
22
9
28
29
30
49
31
10 Feb. total
30 June total
50 Oct. total
11
31
51
7
7
7
12
15
32
15
52
15
Mar.
July
Nov.
13
22
33
22
53
22
14
34
54
31
31
30
15 Mar. total
35 July total
55 Nov. total
16
7
36
7
56
7
17
37
57
15
15
15
Apr.
Aug.
Dec.
18
22
38
22
58
22
19
30
39
31
59
31
20 Apr. total
40 Aug. total
60 Dec. total
61
No. of Forms 1042-S filed: a On paper
b Electronically
62
Total gross amounts reported on all Forms 1042-S and 1000:
a Total U.S. source FDAP income (other than U.S. source substitute payments) reported .
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62a
b Total U.S. source substitute payments reported:
(1) Total U.S. source substitute dividend payments reported .
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62b(1)
(2) Total U.S. source substitute payments reported other than substitute dividend payments
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62b(2)
c Total gross amounts reported (Add lines 62a-b)
62c
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d Enter gross amounts actually paid if different from gross amounts reported .
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62d
Do you want to allow another person to discuss this return with the IRS (see instructions)?
Yes. Complete the following.
No
Third Party
Designee
Designee’s
Phone
Personal identification
name
no.
number (PIN)
▶
▶
▶
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my
knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than withholding agent) is based on all information of which preparer
Sign
has any knowledge.
Here
Date
Capacity in which acting
▶
Your
signature
Daytime phone number
▶
Print/Type preparer’s name
Preparer’s signature
Date
PTIN
Paid
Check
if
self-employed
Preparer
Firm’s name
Use Only
Firm's EIN
▶
▶
Firm’s address
Phone no.
▶
1042
For Privacy Act and Paperwork Reduction Act Notice, see instructions.
Form
(2017)
Cat. No. 11384V

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