Exhibit CC Form 1042-S — Internal Revenue Bulletin 2023-40

Form 1042-S

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

Go to www.irs.gov/Form1042S for instructions and the latest information. ²⁰²³

OMB No. 1545-0096

1 Income code	2 Gross income	2 Gross income	3 Chapter indicator. Enter“3” or“4”	3 Chapter indicator. Enter“3” or“4”	3 Chapter indicator. Enter“3” or“4”	3 Chapter indicator. Enter“3” or“4”	3 Chapter indicator. Enter“3” or“4”	3 Chapter indicator. Enter“3” or“4”	3 Chapter indicator. Enter“3” or“4”	3 Chapter indicator. Enter“3” or“4”	3 Chapter indicator. Enter“3” or“4”	3 Chapter indicator. Enter“3” or“4”	13eRecipient’s U.S. TIN, if any	13eRecipient’s U.S. TIN, if any	13eRecipient’s U.S. TIN, if any	13eRecipient’s U.S. TIN, if any	13fCh. 3 status code	13fCh. 3 status code	13fCh. 3 status code	13fCh. 3 status code	13fCh. 3 status code	13fCh. 3 status code	13fCh. 3 status code
1 Income code	2 Gross income	2 Gross income	3aExemption code	3aExemption code	3aExemption code	3aExemption code	3aExemption code	3aExemption code	3aExemption code	3aExemption code	4aExemption code	4aExemption code	4aExemption code	4aExemption code	4aExemption code	4aExemption code	13gCh. 4 status code	13gCh. 4 status code	13gCh. 4 status code	13gCh. 4 status code	13gCh. 4 status code	13gCh. 4 status code	13gCh. 4 status code
1 Income code	2 Gross income	2 Gross income	. 3bTax rate	. 3bTax rate	. 3bTax rate	. 3bTax rate	. 3bTax rate	. 3bTax rate	. 3bTax rate	. 3bTax rate	. 4bTax rate	. 4bTax rate	13hRecipient’s GIIN	13hRecipient’s GIIN	13iRecipient’s foreign tax identification number, if any	13iRecipient’s foreign tax identification number, if any	13iRecipient’s foreign tax identification number, if any	13iRecipient’s foreign tax identification number, if any	13iRecipient’s foreign tax identification number, if any	13iRecipient’s foreign tax identification number, if any	13iRecipient’s foreign tax identification number, if any	13iRecipient’s foreign tax identification number, if any	13jLOB code
5 Withholding allowance	5 Withholding allowance	5 Withholding allowance	5 Withholding allowance	5 Withholding allowance	5 Withholding allowance	5 Withholding allowance	5 Withholding allowance	5 Withholding allowance	5 Withholding allowance	5 Withholding allowance	5 Withholding allowance	5 Withholding allowance	5 Withholding allowance	5 Withholding allowance	5 Withholding allowance	5 Withholding allowance	5 Withholding allowance	5 Withholding allowance	5 Withholding allowance	5 Withholding allowance	5 Withholding allowance	5 Withholding allowance	5 Withholding allowance
6 Net income	6 Net income	6 Net income	6 Net income	6 Net income	6 Net income
7aFederal tax withheld	7aFederal tax withheld	7aFederal tax withheld	7aFederal tax withheld	7aFederal tax withheld	7aFederal tax withheld								13kRecipient’s account number	13kRecipient’s account number	13kRecipient’s account number	13kRecipient’s account number	13kRecipient’s account number	13kRecipient’s account number	13kRecipient’s account number	13kRecipient’s account number	13kRecipient’s account number	13kRecipient’s account number	13kRecipient’s account number
n 7bCheck if federal tax withheld was escrow procedures were applied (s	n 7bCheck if federal tax withheld was escrow procedures were applied (s	n 7bCheck if federal tax withheld was escrow procedures were applied (s	n 7bCheck if federal tax withheld was escrow procedures were applied (s	n 7bCheck if federal tax withheld was escrow procedures were applied (s	n 7bCheck if federal tax withheld was escrow procedures were applied (s	ot deposited with the IRS because ee instructions) . . . . . .	ot deposited with the IRS because ee instructions) . . . . . .	ot deposited with the IRS because ee instructions) . . . . . .	ot deposited with the IRS because ee instructions) . . . . . .	ot deposited with the IRS because ee instructions) . . . . . .	ot deposited with the IRS because ee instructions) . . . . . .	ot deposited with the IRS because ee instructions) . . . . . .	ot deposited with the IRS because ee instructions) . . . . . .	ot deposited with the IRS because ee instructions) . . . . . .	ot deposited with the IRS because ee instructions) . . . . . .	ot deposited with the IRS because ee instructions) . . . . . .	ot deposited with the IRS because ee instructions) . . . . . .	ot deposited with the IRS because ee instructions) . . . . . .	ot deposited with the IRS because ee instructions) . . . . . .	ot deposited with the IRS because ee instructions) . . . . . .	ot deposited with the IRS because ee instructions) . . . . . .	ot deposited with the IRS because ee instructions) . . . . . .	ot deposited with the IRS because ee instructions) . . . . . .

n 7bCheck if federal tax withheld was escrow procedures were applied (s	n 7bCheck if federal tax withheld was escrow procedures were applied (s	n 7bCheck if federal tax withheld was escrow procedures were applied (s	n 7bCheck if federal tax withheld was escrow procedures were applied (s	n 7bCheck if federal tax withheld was escrow procedures were applied (s	n 7bCheck if federal tax withheld was escrow procedures were applied (s	ot deposited with the IRS because ee instructions) . . . . . .	ot deposited with the IRS because ee instructions) . . . . . .	ot deposited with the IRS because ee instructions) . . . . . .	ot deposited with the IRS because ee instructions) . . . . . .	ot deposited with the IRS because ee instructions) . . . . . .	ot deposited with the IRS because ee instructions) . . . . . .	ot deposited with the IRS because ee instructions) . . . . . .	13l Recipient’s date of birth (YYYYMMDD)	13l Recipient’s date of birth (YYYYMMDD)	13l Recipient’s date of birth (YYYYMMDD)	13l Recipient’s date of birth (YYYYMMDD)	13l Recipient’s date of birth (YYYYMMDD)	13l Recipient’s date of birth (YYYYMMDD)	13l Recipient’s date of birth (YYYYMMDD)	13l Recipient’s date of birth (YYYYMMDD)	13l Recipient’s date of birth (YYYYMMDD)	13l Recipient’s date of birth (YYYYMMDD)	13l Recipient’s date of birth (YYYYMMDD)
7cCheck if withholding occurred in su partnership interest . . . .	7cCheck if withholding occurred in su partnership interest . . . .	7cCheck if withholding occurred in su partnership interest . . . .	7cCheck if withholding occurred in su partnership interest . . . .	7cCheck if withholding occurred in su partnership interest . . . .	7cCheck if withholding occurred in su partnership interest . . . .	bsequent year with respect to a . . . . . . . . . .	bsequent year with respect to a . . . . . . . . . .	bsequent year with respect to a . . . . . . . . . .	bsequent year with respect to a . . . . . . . . . .	bsequent year with respect to a . . . . . . . . . .	bsequent year with respect to a . . . . . . . . . .	bsequent year with respect to a . . . . . . . . . .	bsequent year with respect to a . . . . . . . . . .	bsequent year with respect to a . . . . . . . . . .	bsequent year with respect to a . . . . . . . . . .	bsequent year with respect to a . . . . . . . . . .	bsequent year with respect to a . . . . . . . . . .	bsequent year with respect to a . . . . . . . . . .	bsequent year with respect to a . . . . . . . . . .	bsequent year with respect to a . . . . . . . . . .	bsequent year with respect to a . . . . . . . . . .	bsequent year with respect to a . . . . . . . . . .	bsequent year with respect to a . . . . . . . . . .
8 Tax withheld by other agents	8 Tax withheld by other agents	8 Tax withheld by other agents	8 Tax withheld by other agents	8 Tax withheld by other agents	8 Tax withheld by other agents								14aPrimary WithholdingAgent’s Name (if applicable)	14aPrimary WithholdingAgent’s Name (if applicable)	14aPrimary WithholdingAgent’s Name (if applicable)	14aPrimary WithholdingAgent’s Name (if applicable)	14aPrimary WithholdingAgent’s Name (if applicable)	14aPrimary WithholdingAgent’s Name (if applicable)	14aPrimary WithholdingAgent’s Name (if applicable)	14aPrimary WithholdingAgent’s Name (if applicable)	14aPrimary WithholdingAgent’s Name (if applicable)	14aPrimary WithholdingAgent’s Name (if applicable)	14aPrimary WithholdingAgent’s Name (if applicable)
9 Overwithheld tax repaid to recipient pursu (	9 Overwithheld tax repaid to recipient pursu (	9 Overwithheld tax repaid to recipient pursu (	9 Overwithheld tax repaid to recipient pursu (	9 Overwithheld tax repaid to recipient pursu (	9 Overwithheld tax repaid to recipient pursu (	ant to adjustment procedures (see instructions) )	ant to adjustment procedures (see instructions) )	ant to adjustment procedures (see instructions) )	ant to adjustment procedures (see instructions) )	ant to adjustment procedures (see instructions) )	ant to adjustment procedures (see instructions) )	ant to adjustment procedures (see instructions) )	ant to adjustment procedures (see instructions) )	ant to adjustment procedures (see instructions) )	ant to adjustment procedures (see instructions) )	ant to adjustment procedures (see instructions) )	ant to adjustment procedures (see instructions) )	ant to adjustment procedures (see instructions) )	ant to adjustment procedures (see instructions) )	ant to adjustment procedures (see instructions) )	ant to adjustment procedures (see instructions) )	ant to adjustment procedures (see instructions) )	ant to adjustment procedures (see instructions) )

9 Overwithheld tax repaid to recipient pursu (	9 Overwithheld tax repaid to recipient pursu (	9 Overwithheld tax repaid to recipient pursu (	9 Overwithheld tax repaid to recipient pursu (	9 Overwithheld tax repaid to recipient pursu (	9 Overwithheld tax repaid to recipient pursu (	ant to adjustment procedures (see instructions) )	ant to adjustment procedures (see instructions) )	ant to adjustment procedures (see instructions) )	ant to adjustment procedures (see instructions) )	ant to adjustment procedures (see instructions) )	ant to adjustment procedures (see instructions) )	ant to adjustment procedures (see instructions) )	14bPrimary WithholdingAgent’s EIN	14bPrimary WithholdingAgent’s EIN	14bPrimary WithholdingAgent’s EIN	14bPrimary WithholdingAgent’s EIN	15Check if pro-rata basis reporting	15Check if pro-rata basis reporting	15Check if pro-rata basis reporting	15Check if pro-rata basis reporting	15Check if pro-rata basis reporting	15Check if pro-rata basis reporting	15Check if pro-rata basis reporting
b 10Total withholding credit (combine	b 10Total withholding credit (combine	b 10Total withholding credit (combine	b 10Total withholding credit (combine	b 10Total withholding credit (combine	b 10Total withholding credit (combine	oxes 7a, 8, and 9)	oxes 7a, 8, and 9)	oxes 7a, 8, and 9)	oxes 7a, 8, and 9)	oxes 7a, 8, and 9)	oxes 7a, 8, and 9)	oxes 7a, 8, and 9)	oxes 7a, 8, and 9)	oxes 7a, 8, and 9)	oxes 7a, 8, and 9)	oxes 7a, 8, and 9)	oxes 7a, 8, and 9)	oxes 7a, 8, and 9)	oxes 7a, 8, and 9)	oxes 7a, 8, and 9)	oxes 7a, 8, and 9)	oxes 7a, 8, and 9)	oxes 7a, 8, and 9)
b 10Total withholding credit (combine	b 10Total withholding credit (combine	b 10Total withholding credit (combine	b 10Total withholding credit (combine	b 10Total withholding credit (combine	b 10Total withholding credit (combine	oxes 7a, 8, and 9)	oxes 7a, 8, and 9)	oxes 7a, 8, and 9)	oxes 7a, 8, and 9)	oxes 7a, 8, and 9)	oxes 7a, 8, and 9)	oxes 7a, 8, and 9)	15aIntermediary or flow-throughentity’s EIN, if any	15aIntermediary or flow-throughentity’s EIN, if any	15aIntermediary or flow-throughentity’s EIN, if any	15aIntermediary or flow-throughentity’s EIN, if any	15aIntermediary or flow-throughentity’s EIN, if any	15b Ch. 3 status code	15b Ch. 3 status code	15b Ch. 3 status code	15b Ch. 3 status code	15c Ch. 4 status code	15c Ch. 4 status code
11Tax paid by withholding agent (am	11Tax paid by withholding agent (am	11Tax paid by withholding agent (am	11Tax paid by withholding agent (am	11Tax paid by withholding agent (am	11Tax paid by withholding agent (am	unts not withheld) (see instructions)	unts not withheld) (see instructions)	unts not withheld) (see instructions)	unts not withheld) (see instructions)	unts not withheld) (see instructions)	unts not withheld) (see instructions)	unts not withheld) (see instructions)	unts not withheld) (see instructions)	unts not withheld) (see instructions)	unts not withheld) (see instructions)	unts not withheld) (see instructions)	unts not withheld) (see instructions)	unts not withheld) (see instructions)	unts not withheld) (see instructions)	unts not withheld) (see instructions)	unts not withheld) (see instructions)	unts not withheld) (see instructions)	unts not withheld) (see instructions)
11Tax paid by withholding agent (am	11Tax paid by withholding agent (am	11Tax paid by withholding agent (am	11Tax paid by withholding agent (am	11Tax paid by withholding agent (am	11Tax paid by withholding agent (am	unts not withheld) (see instructions)	unts not withheld) (see instructions)	unts not withheld) (see instructions)	unts not withheld) (see instructions)	unts not withheld) (see instructions)	unts not withheld) (see instructions)	unts not withheld) (see instructions)	15dIntermediary or flow-throughentity’s name	15dIntermediary or flow-throughentity’s name	15dIntermediary or flow-throughentity’s name	15dIntermediary or flow-throughentity’s name	15dIntermediary or flow-throughentity’s name	15dIntermediary or flow-throughentity’s name	15dIntermediary or flow-throughentity’s name	15dIntermediary or flow-throughentity’s name	15dIntermediary or flow-throughentity’s name	15dIntermediary or flow-throughentity’s name	15dIntermediary or flow-throughentity’s name
12aWithholdingagent’s EIN	12aWithholdingagent’s EIN	12aWithholdingagent’s EIN	12aWithholdingagent’s EIN	12aWithholdingagent’s EIN	12aWithholdingagent’s EIN	12bCh. 3 status code	12bCh. 3 status code	12bCh. 3 status code	12bCh. 3 status code	12bCh. 3 status code	12bCh. 3 status code	12cCh. 4 status code	12cCh. 4 status code	12cCh. 4 status code	12cCh. 4 status code	12cCh. 4 status code	12cCh. 4 status code	12cCh. 4 status code	12cCh. 4 status code	12cCh. 4 status code	12cCh. 4 status code	12cCh. 4 status code	12cCh. 4 status code

12aWithholdingagent’s EIN	12aWithholdingagent’s EIN	12aWithholdingagent’s EIN	12aWithholdingagent’s EIN	12aWithholdingagent’s EIN	12aWithholdingagent’s EIN	12bCh. 3 status code	12bCh. 3 status code	12bCh. 3 status code	12bCh. 3 status code	12bCh. 3 status code	12bCh. 3 status code	12cCh. 4 status code	15eIntermediary or flow-throughentity’s GIIN	15eIntermediary or flow-throughentity’s GIIN	15eIntermediary or flow-throughentity’s GIIN	15eIntermediary or flow-throughentity’s GIIN	15eIntermediary or flow-throughentity’s GIIN	15eIntermediary or flow-throughentity’s GIIN	15eIntermediary or flow-throughentity’s GIIN	15eIntermediary or flow-throughentity’s GIIN	15eIntermediary or flow-throughentity’s GIIN	15eIntermediary or flow-throughentity’s GIIN	15eIntermediary or flow-throughentity’s GIIN
12dWithholdingagent’s name	12dWithholdingagent’s name	12dWithholdingagent’s name	12dWithholdingagent’s name	12dWithholdingagent’s name	12dWithholdingagent’s name								15fCountry code	15gForeign tax identification number, if any	15gForeign tax identification number, if any	15gForeign tax identification number, if any	15gForeign tax identification number, if any	15gForeign tax identification number, if any	15gForeign tax identification number, if any	15gForeign tax identification number, if any	15gForeign tax identification number, if any	15gForeign tax identification number, if any	15gForeign tax identification number, if any
12eWithholding agent’s Global Interm	12eWithholding agent’s Global Interm	12eWithholding agent’s Global Interm	12eWithholding agent’s Global Interm	12eWithholding agent’s Global Interm	12eWithholding agent’s Global Interm	ediary Identification Number(GIIN) 5.30 in	ediary Identification Number(GIIN) 5.30 in	ediary Identification Number(GIIN) 5.30 in	ediary Identification Number(GIIN) 5.30 in	ediary Identification Number(GIIN) 5.30 in	ediary Identification Number(GIIN) 5.30 in	ediary Identification Number(GIIN) 5.30 in	15hAddress (number and street)	15hAddress (number and street)	15hAddress (number and street)	15hAddress (number and street)	15hAddress (number and street)	15hAddress (number and street)	15hAddress (number and street)	15hAddress (number and street)	15hAddress (number and street)	15hAddress (number and street)	15hAddress (number and street)
12fCountry code	12fCountry code	12gForeign	12gForeign	12gForeign	12gForeign	tax identification number, if any	tax identification number, if any	tax identification number, if any	tax identification number, if any	tax identification number, if any	tax identification number, if any	tax identification number, if any	15iCity or town, state or province, country, ZIP or foreign postal code	15iCity or town, state or province, country, ZIP or foreign postal code	15iCity or town, state or province, country, ZIP or foreign postal code	15iCity or town, state or province, country, ZIP or foreign postal code	15iCity or town, state or province, country, ZIP or foreign postal code	15iCity or town, state or province, country, ZIP or foreign postal code	15iCity or town, state or province, country, ZIP or foreign postal code	15iCity or town, state or province, country, ZIP or foreign postal code	15iCity or town, state or province, country, ZIP or foreign postal code	15iCity or town, state or province, country, ZIP or foreign postal code	15iCity or town, state or province, country, ZIP or foreign postal code
12hAddress (number and street)	12hAddress (number and street)	12hAddress (number and street)	12hAddress (number and street)	12hAddress (number and street)	12hAddress (number and street)								16aPayer’s name	16aPayer’s name	16aPayer’s name	16aPayer’s name	16aPayer’s name	16aPayer’s name	16bPayer’s TIN	16bPayer’s TIN	16bPayer’s TIN	16bPayer’s TIN	16bPayer’s TIN
12iCity or town, state or province, cou	12iCity or town, state or province, cou	12iCity or town, state or province, cou	12iCity or town, state or province, cou	12iCity or town, state or province, cou	12iCity or town, state or province, cou	ntry, ZIP or foreign postal code	ntry, ZIP or foreign postal code	ntry, ZIP or foreign postal code	ntry, ZIP or foreign postal code	ntry, ZIP or foreign postal code	ntry, ZIP or foreign postal code	ntry, ZIP or foreign postal code	16cPayer’s GIIN	16cPayer’s GIIN	16cPayer’s GIIN	16cPayer’s GIIN	16dCh. 3 status code	16dCh. 3 status code	16dCh. 3 status code	16dCh. 3 status code	16eCh. 4 status code	16eCh. 4 status code	16eCh. 4 status code

13aRecipient’sname	13aRecipient’sname	13aRecipient’sname	13aRecipient’sname	13aRecipient’sname	13aRecipient’sname			13bRecipient’s country code	13bRecipient’s country code	13bRecipient’s country code	13bRecipient’s country code	13bRecipient’s country code	17aState income tax withheld 7.30 in	17aState income tax withheld 7.30 in	17aState income tax withheld 7.30 in	17bPayer’s state tax no.	17bPayer’s state tax no.	17bPayer’s state tax no.	17bPayer’s state tax no.	17cName of state	17cName of state	17cName of state	17cName of state
13cAddress (number and street)	13cAddress (number and street)	13cAddress (number and street)	13cAddress (number and street)	13cAddress (number and street)	13cAddress (number and street)
13dCity or town, state or province, country, ZIP or foreign postal code

October 2, 2023 1056 Bulletin No. 2023–40

(88 FR 11754). The TFA electronic filing regulations implement the 10-return mandatory electronic filing threshold with respect to Forms 8955-SSA and 5500-EZ, among other forms, that are required to be filed for plan years beginning on or after January 1, 2024. ³

.06 Similar to the 2014 electronic filing regulations, §§ 301.6057-3 and 301.6058-2 of the TFA electronic filing regulations provide that the Commissioner may grant waivers of the electronic filing requirement in cases of undue hardship or undue economic hardship, respectively. The TFA electronic filing regulations provide that a request for a waiver must be made in accordance with applicable IRS revenue procedures, publications, forms, instructions, or other guidance, including postings to the IRS.gov website.

.07 In addition to a hardship waiver, § 301.6057-3(b)(2) of the TFA electronic filing regulations states that the Commissioner may provide an exemption from the requirement to file Form 8955SSA electronically to promote effective and efficient tax administration. The TFA electronic filing regulations provide that a submission claiming an exemption must be made in accordance with applicable IRS revenue procedures, publications, forms, instructions, or other guidance, including postings to the IRS.gov website. ⁴