Form

1042-S

Foreign Person’s U.S. Source Income

OMB No. 1545-0096

Subject to Withholding

Copy A for

Department of the Treasury Internal Revenue Service

AMENDED

PRO-RATA BASIS REPORTING

Internal Revenue Service

1Income

code

2 Gross income

3Withholding

allowances

 4 Net income

5Tax rate

6Exemption

code

 7 U.S. Federal tax

withheld

8 Amount repaid to

recipient

9 Withholding agent’s EIN

QI-EIN

14 Recipient’s U.S. TIN, if any

QI-EIN

EIN

SSN or ITIN

EIN

10a WITHHOLDING AGENT’S name

Check here

if nominee

15 Recipient’s country of residence for tax purposes

16 Country code

	

17 NONQUALIFIED INTERMEDIARY’S (NQI’s)/ FLOW-THROUGH ENTITY’S name

18 Country code

10d City or town, province or state, and country

10e ZIP code or foreign postal code

	

11 Recipient’s account number (optional)

12 Recipient code

19c City or town, province or state, and country

19d ZIP code or foreign postal code

	

20 NQI’s/Flow-through entity’s TIN, if any	

13d City or town, province or state, and country

13e ZIP code or foreign postal code

22 State income tax withheld

23 Payer’s state tax no.

24 Name of state

For Privacy Act and Paperwork Reduction Act Notice, see page 15 of the separate instructions.

Cat. No. 1 1386R

Form 1 042-S (2006)

10bAddress (number and street)

10c Additional address line (room or suite no.)

19a NQI’s/Flow-through entity’s address (number and street)

19b Additional address line (room or suite no.)

13a RECIPIENT’S name

13b Address (number and street)

13cAdditional address line (room or suite no.)

21 PAYER’S name and TIN (if different from withholding agent’s)

□

2006

Form

1042-S

Foreign Person’s U.S. Source Income

OMB No. 1545-0096

Subject to Withholding

Copy B

Department of the Treasury Internal Revenue Service

AMENDED

PRO-RATA BASIS REPORTING

for Recipient

1Income

code

2 Gross income

3Withholding

allowances

 4 Net income

5Tax rate

6Exemption

code

 7 U.S. Federal tax

withheld

8 Amount repaid to

recipient

9 Withholding agent’s EIN

QI-EIN

14 Recipient’s U.S. TIN, if any

QI-EIN

EIN

SSN or ITIN

EIN

10a WITHHOLDING AGENT’S name

Check here

if nominee

15 Recipient’s country of residence for tax purposes

16 Country code

	

17 NONQUALIFIED INTERMEDIARY’S (NQI’s)/ FLOW-THROUGH ENTITY’S name

18 Country code

10d City or town, province or state, and country

10e ZIP code or foreign postal code

	

11 Recipient’s account number (optional)

12 Recipient code

19c City or town, province or state, and country

19d ZIP code or foreign postal code

	

20 NQI’s/Flow-through entity’s TIN, if any	

13d City or town, province or state, and country

13e ZIP code or foreign postal code

22 State income tax withheld

23 Payer’s state tax no.

24 Name of state

Form 1 042-S (2006)

10bAddress (number and street)

10c Additional address line (room or suite no.)

19a NQI’s/Flow-through entity’s address (number and street)

19b Additional address line (room or suite no.)

13a RECIPIENT’S name

13b Address (number and street)

13cAdditional address line (room or suite no.)

21 PAYER’S name and TIN (if different from withholding agent’s)

□

2006

U.S. Income Tax Filing Requirements

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

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: National Distribution Center, P.O. Box 8903, Bloomington, IL

los Estados Unidos, deberá presentar una declaración

61 702-8903, U.S.A.

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 1 040NR (o la Forma 1 040NR-EZ si le corresponde).) Se podrán obtener formas e instrucciones en cualquier Embajada o Consulado de los Estados Unidos o escribiendo directamente a: National Distribution Center,

Tout étranger non-résident, tout organisme fidéicommissaire étranger non-résident et toute société étrangère percevant un revenu

P.O. Box 8903, Bloomington, IL 61 702-8903, U.S.A.

aux Etats-Unis, y compris tout revenu dérivé, en fait, du

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, müssen 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: National Distribution Center, P.O. Box 8903, Bloomington, IL 61 702-8903, U.S.A.

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: National Distribution Center, P.O. Box 8903, Bloomington, IL 61702-8903, U.S.A.

Form

1042-S

Subject to Withholding

Foreign Person’s U.S. Source Income

OMB No. 1545-0096

Department of the Treasury Internal Revenue Service

AMENDED

PRO-RATA BASIS REPORTING

Copy C for Recipient
Attach to any Federal tax return you file

1Income

code

2 Gross income

3Withholding

allowances

 4 Net income

5Tax rate

6Exemption

code

 7 U.S. Federal tax

withheld

8 Amount repaid to

recipient

9 Withholding agent’s EIN

QI-EIN

14 Recipient’s U.S. TIN, if any

QI-EIN

EIN

SSN or ITIN

EIN

10a WITHHOLDING AGENT’S name

Check here

if nominee

15 Recipient’s country of residence for tax purposes

16 Country code

	

17 NONQUALIFIED INTERMEDIARY’S (NQI’s)/ FLOW-THROUGH ENTITY’S name

18 Country code

10d City or town, province or state, and country

10e ZIP code or foreign postal code

	

11 Recipient’s account number (optional)

12 Recipient code

19c City or town, province or state, and country

19d ZIP code or foreign postal code

	

20 NQI’s/Flow-through entity’s TIN, if any	

13d City or town, province or state, and country

13e ZIP code or foreign postal code

22 State income tax withheld

23 Payer’s state tax no.

24 Name of state

Form 1 042-S (2006)

10bAddress (number and street)

10c Additional address line (room or suite no.)

19a NQI’s/Flow-through entity’s address (number and street)

19b Additional address line (room or suite no.)

13a RECIPIENT’S name

13b Address (number and street)

13cAdditional address line (room or suite no.)

21 PAYER’S name and TIN (if different from withholding agent’s)

□

2006

Explanation of Codes

Box 1. Income code.

Box 6. Exemption code (applies if the tax rate entered in box 5 is 00.00).

Code
01 Interest paid by U.S. obligors—general
02 Interest paid on real property mortgages
03 Interest paid to controlling foreign corporations

Types of Income

Code

Authority for Exemption

01

Income effectively connected with a U.S. trade or business
Exempt under an Internal Revenue Code section (income other than

02

•	

portfolio interest)

Income is not from U.S. sources4

29 Deposit interest

pygp
•	05 Interest on tax-free covenant bonds

00000004356897

Exempt under tax treaty
Portfolio interest exempt under an Internal Revenue Code section Qualified intermediary that assumes primary withholding responsibility Withholding foreign partnership or withholding foreign trust

30 Original issue discount (OID)

31 Short-term OID

33 Substitute payment—interest

U.S. branch treated as a U.S. person

06Dividends paid by U.S. corporations—general 07 Dividends qualifying for direct dividend rate

Qualified intermediary represents income is exempt

08 Dividends paid by foreign corporations 34 Substitute payment—dividends

Box 12. Recipient code.

Code

Type of Recipient

09 Capital gains

82345634902711

Individual2

10 Industrial royalties

Corporation2

11 Motion picture or television copyright royalties
12 Other royalties (e.g., copyright, recording, publishing)
13 Real property income and natural resources royalties
14 Pensions, annuities, alimony, and/or insurance premiums

Partnership other than withholding foreign partnership2 Withholding foreign partnership or withholding foreign trust

Trust

15 Scholarship or fellowship grants

Government or international organization Tax-exempt organization (IRC section 501(a))

16 Compensation for independent personal services1
17 Compensation for dependent personal services1

Private foundation

18 Compensation for teaching1

Artist or athlete2

19 Compensation during studying and training1

Estate

20 Earnings as an artist or athlete

U.S. branch treated as U.S. person

24 Real estate investment trust (REIT) distributions of capital gains

Qualified intermediary

25 Trust distributions subject to IRC section 1445

Private arrangement intermediary withholding rate pool—general5 Private arrangement intermediary withholding rate pool—

26 Unsevered growing crops and timber distributions by a trust subject

to IRC section 1445

exempt organizations5

27 Publicly traded partnership distributions subject to IRC section 1446

15

Qualified intermediary withholding rate pool—general5
Qualified intermediary withholding rate pool—exempt organizations5 Authorized foreign agent
Public pension fund

28 Gambling winnings6

16

32 Notional principal contract income 35 Substitute payment—other

17

18

36 Capital gains distributions 50 Other income

20

Unknown recipient

1 If compensation that otherwise would be covered under Income Codes 16–19 is directly attributable to the recipient’s occupation as an artist or athlete, use Income Code 20 instead.
2 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

3 oregnpartnersp).

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.

Form

1042-S

Subject to Withholding

Foreign Person’s U.S. Source Income

OMB No. 1545-0096

Department of the Treasury Internal Revenue Service

AMENDED

PRO-RATA BASIS REPORTING

Copy D for Recipient
Attach to any state tax return you file

1Income

code

2 Gross income

3Withholding

allowances

 4 Net income

5Tax rate

6Exemption

code

 7 U.S. Federal tax

withheld

8 Amount repaid to

recipient

9 Withholding agent’s EIN

QI-EIN

14 Recipient’s U.S. TIN, if any

QI-EIN

EIN

SSN or ITIN

EIN

10a WITHHOLDING AGENT’S name

Check here

if nominee

15 Recipient’s country of residence for tax purposes

16 Country code

	

17 NONQUALIFIED INTERMEDIARY’S (NQI’s)/ FLOW-THROUGH ENTITY’S name

18 Country code

10d City or town, province or state, and country

10e ZIP code or foreign postal code

	

11 Recipient’s account number (optional)

12 Recipient code

19c City or town, province or state, and country

19d ZIP code or foreign postal code

	

20 NQI’s/Flow-through entity’s TIN, if any	

13d City or town, province or state, and country

13e ZIP code or foreign postal code

22 State income tax withheld

23 Payer’s state tax no.

24 Name of state

Form 1 042-S (2006)

10bAddress (number and street)

10c Additional address line (room or suite no.)

19a NQI’s/Flow-through entity’s address (number and street)

19b Additional address line (room or suite no.)

13a RECIPIENT’S name

13b Address (number and street)

13cAdditional address line (room or suite no.)

21 PAYER’S name and TIN (if different from withholding agent’s)

□

2006

Form

1042-S

Foreign Person’s U.S. Source Income

OMB No. 1545-0096

Subject to Withholding

Copy E

Department of the Treasury Internal Revenue Service

AMENDED

PRO-RATA BASIS REPORTING

for Withholding Agent

1Income

code

2 Gross income

3Withholding

allowances

 4 Net income

5Tax rate

6Exemption

code

7 U.S. Federal tax

withheld

8 Amount repaid to

recipient

9 Withholding agent’s EIN

QI-EIN

14 Recipient’s U.S. TIN, if any

QI-EIN

EIN

SSN or ITIN

EIN

10aWITHHOLDING AGENT’S name

Check here

if nominee

15Recipient’s country of residence for tax purposes

 16 Country code

	

17 NONQUALIFIED INTERMEDIARY’S (NQI’s)/ FLOW-THROUGH ENTITY’S name

18 Country code

10d City or town, province or state, and country

10e ZIP code or foreign postal code

	

11 Recipient’s account number (optional)

12 Recipient code

19c City or town, province or state, and country

19d ZIP code or foreign postal code

	

20 NQI’s/Flow-through entity’s TIN, if any	

13d City or town, province or state, and country

13e ZIP code or foreign postal code

22 State income tax withheld

23 Payer’s state tax no.

24 Name of state

Form 1 042-S (2006)

10bAddress (number and street)

10c Additional address line (room or suite no.)

19a NQI’s/Flow-through entity’s address (number and street)

19b Additional address line (room or suite no.)

13a RECIPIENT’S name

13b Address (number and street)

13cAdditional address line (room or suite no.)

21 PAYER’S name and TIN (if different from withholding agent’s)

□

2006