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 ____________________________