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Form 1042, Annual Withholding Tax Return for U.S. Source Income of Foreign Persons

This is an annual withholding tax return for a U.S. source of income for foreign persons. The form provided here is simply a sample of what the actual Form 1042 looks like.

Form 1042
OMB No. 1545-0096

Department of the Treasury
Internal Revenue Service

If this is an Amended Return, check here ____

If completing only Part II as a transmittal document, check here ____

Name of withholding agent ____________________________

Taxpayer identification number ____________________________

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

____________________________

____________________________

If you will not be liable for returns in the future, check here ____

Enter date final income paid ____________________________

Check here if you made quarter-monthly deposits using the 90% rule (see Deposit Requirements in the instructions)

Part I Record of Federal Tax Liability
(Do not show Federal tax deposits here.)

Line No. 1 Period ending Jan 7

Tax liability for period (including any taxes assumed on Form(s) 1000) __________________

Line No. 2 Period ending Jan 15

Tax liability for period (including any taxes assumed on Form(s) 1000) __________________

Line No. 3 Period ending Jan 22

Tax liability for period (including any taxes assumed on Form(s) 1000) __________________

Line No. 4 Period ending Jan 31

Tax liability for period (including any taxes assumed on Form(s) 1000) __________________

Line No. 5 Period ending Jan Total

Tax liability for period (including any taxes assumed on Form(s) 1000) __________________

...

Line No. 56 Period ending Dec 7

Tax liability for period (including any taxes assumed on Form(s) 1000) __________________

Line No. 57 Period ending Dec 15

Tax liability for period (including any taxes assumed on Form(s) 1000) __________________

Line No. 58 Period ending Dec 22

Tax liability for period (including any taxes assumed on Form(s) 1000) __________________

Line No. 59 Period ending Dec 31

Tax liability for period (including any taxes assumed on Form(s) 1000) __________________

Line No. 60 Period ending Dec Total

Tax liability for period (including any taxes assumed on Form(s) 1000) __________________

61a Total tax liability (add monthly total lines from above) 61a __________________

b Adjustments (see instructions) 61b __________________

c Total net tax liability (combine lines 61a and 61b) 61c __________________

62 No. of Forms 1042-S filed on:

a Magnetic tape __________________

b Paper with this form __________________

c Paper with previously filed Form(s) 1042 (Parts I or II) __________________

63 For all Form(s) 1042-S and 1000:

a Gross income paid __________________

b Taxes withheld or assumed __________________

64 Total paid by Federal tax deposit coupons or by electronic funds transfer (or with a request for an extension of time to file) for 1999 64 __________________

65 Enter overpayment applied as a credit from 1998 Form 1042 65 __________________

66 Total payments. Add lines 64 and 65 66 __________________

67 If line 61c is larger than line 66, enter BALANCE DUE here 67 __________________

68 If line 66 is larger than line 61c, enter OVERPAYMENT here 68 __________________

69 Apply overpayment on line 68 to (check one):

____ Credit on 2000 Form 1042; or ____ Refund

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.

Sign Here

Your signature ____________________________

Date ____________________________

Capacity in which acting ____________________________

Paid Preparer's Use Only

Preparer's signature ____________________________

Date ____________________________

Check if self-employed ____

Preparer's SSN or PTIN ____________________________

Firm's name (or yours if self-employed) and address

____________________________

____________________________

EIN ____________________________

ZIP code ____________________________

For Privacy Act and Paperwork Reduction Act Notice, see the instructions. Form 1042 (1999)

Part II Transmittal of Paper Forms 1042-S

DO NOT complete Part II if you are completing Part I of this Form 1042.

Name of withholding agent ____________________________

Taxpayer identification number ____________________________

70 Complete this line only if you have not yet filed a 1999 Form 1042 (Part I).

Number of paper Forms 1042-S attached:

a Original ____________________________

b Voided ____________________________

c Corrected ____________________________

71 Complete this line if you have already filed a 1999 Form 1042 (Part I).

Caution: You cannot use Part II to transmit any Forms 1042-S that would cause the gross income or tax withheld information shown on your previously filed Form 1042 (Part I) to change. Instead, you must file an amended Form 1042 (Part I). See the instructions.

Number of paper Forms 1042-S attached:

a Original ____________________________

b Voided ____________________________

c Corrected ____________________________

72 Number of paper Forms 1042-S previously filed with Form 1042 (Parts I or II), if applicable ____________________________

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