Foreign Person's U.S. Source Income Subject to Withholding Revision Date 12/13/2021

• Issuer: Treasury Department
• Section: Treasury Department

Form 1042-S

Department of the Treasury

Internal Revenue Service

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

Go to www.irs.gov/Form1042S for instructions and the latest information. 2024

UNIQUE FORM IDENTIFIER

AMENDED

AMENDMENT NO.

OMB No. 1545-0096

Copy A for

Internal Revenue Service

1 Income

code

2 Gross income 3 Chapter indicator. Enter “3” or “4”

3a Exemption code

3b Tax rate .

4a

Exemption code

4b Tax rate .

5 Withholding allowance

6 Net income

7a Federal tax withheld

7b Check if federal tax withheld was not deposited with the IRS because

escrow procedures were applied (see instructions) . . . . . .

7c Check if withholding occurred in subsequent year with respect to a

partnership interest . . . . . . . . . . . . . .

8 Tax withheld by other agents

9

Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)

( )

10 Total withholding credit (combine boxes 7a, 8, and 9)

11 Tax paid by withholding agent (amounts not withheld) (see instructions)

12a Withholding agent

’

s EIN 12b

Ch. 3 status code

12c

Ch. 4 status code

12d Withholding agent

’

s name

12e Withholding agent

’

s Global Intermediary Identification Number (GIIN)

12f Country code 12g Foreign tax identification number, if any

12h Address (number and street)

12i City or town, state or province, country, ZIP or foreign postal code

13a Recipient

’

s name 13b Recipient

’

s country code

13c

Address (number and street)

13d City or town, state or province, country, ZIP or foreign postal code

13e Recipient’s U.S. TIN, if any 13f Ch. 3 status code

13g Ch. 4 status code

13h Recipient’s GIIN 13i

Recipient

’

s

foreign tax identification

number, if any

13j

LOB code

13k Recipient

’

s account number

13l Recipient

’

s date of birth (YYYYMMDD)

14a

Primary Withholding Agent

’

s

Name (if applicable)

14b Primary Withholding Agent

’

s EIN

15 Check if pro-rata basis reporting

15a

Intermediary or flow-through entity’s EIN, if any

15b

Ch. 3 status code

15c

Ch. 4 status code

15d

Intermediary or flow-through entity’s name

15e

Intermediary or flow-through entity’s GIIN

15f Country code 15g Foreign tax identification number, if any

15h Address (number and street)

15i City or town, state or province, country, ZIP or foreign postal code

16a Payer

’

s name 16b Payer

’

s TIN

16c Payer

’

s GIIN 16d

Ch. 3 status code

16e

Ch. 4 status code

17a State income tax withheld 17b Payer

’

s state tax no. 17c Name of state

For Privacy Act and Paperwork Reduction Act Notice, see instructions.

Cat. No. 11386R Form 1042-S (2024)