Annual Withholding Tax Return for U.S. Source Income of Foreign Persons

• Issuer: Treasury Department
• Section: Treasury Department

Form 1042

Department of the Treasury

Internal Revenue Service

Annual Withholding Tax Return for U.S. Source

Income of Foreign Persons

Go to www.irs.gov/Form1042 for instructions and the latest information.

OMB No. 1545-0096

2023

If this is an amended return, check here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Name of withholding agent Employer identification number

Ch. 3 Status Code Ch. 4 Status Code

Number, street, and room or suite no. (If a P.O. box, see instructions.)

City or town, state or province, country, and ZIP or foreign postal code

For IRS Use Only

CC

RD

CAF

CR

EDC

FD

FF

FP

I

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)

Jan.

Feb.

Mar.

Apr.

May

June

July

Aug.

Sept.

Oct.

Nov.

Dec.

Line

No.

Period

ending

Tax liability for period

(including any taxes assumed

on Form(s) 1000)

1 7

2 15

3 22

4 31

5Jan. total

6 7

7 15

8 22

9 28

10 Feb. total

11 7

12 15

13 22

14 31

15 Mar. total

16 7

17 15

18 22

19 30

20 Apr. total

Line

No.

Period

ending

Tax liability for period

(including any taxes assumed

on Form(s) 1000)

21 7

22 15

23 22

24 31

25 May total

26 7

27 15

28 22

29 30

30 June total

31 7

32 15

33 22

34 31

35 July total

36 7

37 15

38 22

39 31

40 Aug. total

Line

No.

Period

ending

Tax liability for period

(including any taxes assumed

on Form(s) 1000)

41 7

42 15

43 22

44 30

45 Sept. total

46 7

47 15

48 22

49 31

50 Oct. total

51 7

52 15

53 22

54 30

55 Nov. total

56 7

57 15

58 22

59 31

60 Dec. total

Note: The totals from the above table are to be entered on lines 64b through 64d (as indicated in the instructions for those lines).

61 No. of Forms 1042-S filed: a On paper b Electronically

62 Total gross amounts reported on all Forms 1042-S and 1000:

aTotal U.S. source FDAP income (other than U.S. source substitute payments) reported . . . . . 62a

bTotal U.S. source substitute payments reported:

(1) Total U.S. source substitute dividend payments reported . . . . . . . . . . . . . .

62b(1)

(2) Total U.S. source substitute payments reported other than substitute dividend payments . . .

62b(2)

c Total gross amounts reported (add lines 62a–b) . . . . . . . . . . . . . . . . . 62c

dEnter gross amounts actually paid if different from gross amounts reported . . . . . . . . . 62d

Third Party

Designee

Do you want to allow another person to discuss this return with the IRS? See instructions.

Yes. Complete the following.

No

Designee’s

name

Phone

no.

Personal identification

number (PIN)

Sign

Here

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

has any knowledge.

Your

signature

Date Capacity in which acting

Daytime phone number

Paid

Preparer

Use Only

Print/Type preparer’s name Preparer’s signature Date Check if

self-employed

PTIN

Firm’s name

Firm’s address

Firm’s EIN

Phone no.

For Privacy Act and Paperwork Reduction Act Notice, see instructions. Cat. No. 11384V Form 1042 (2023)