1042-S 2021

1042-S - Foreign Person's U.S. Source Income Subject to Withholding.

UNIQUE FORM IDENTIFIER

AMENDMENT NO.

UNIQUE FORM IDENTIFIERAMENDED

1 Income code

2 Gross income

3 Chapter indicator. Enter "3" or "4"

3a Exemption code

3b Tax rate

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

13I Recipient's date of birth (YYYYMMDD)

Date

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