Part III — 1024 Publ 5876 (PDF)

Use these tips when completing Part III of Form 8843 for students.

Line	Tip
Enter the name, address, and telephone number of the academic institution you attended during 2024	Students who attend more than one academic institution during the year should report the one they attended at the end of the year.
Enter the name, address, and telephone number of the director of the academic or other specialized program you participated in during 2024	This should be someone the IRS can contact, if necessary, to verify that the student was present at the school. Students can list the foreign student advisor if necessary.
Enter the type of U.S. visa (F, J, or M) you held during…	If the type of visa you held during any of these years changed, attach a statement showing the new visa type and the date it was acquired.
Were you exempt as a teacher, trainee, or student for any part of more than 5 calendar years? If you checked the “Yes” box on line 12, you must provide sufficient facts on an attached statement to establish that you do not intend to reside permanently in the United States.	Self explanatory. However, if claiming the closer connection exception, please include a statement indicating that the election to exclude days beyond the 5-year period is being made, and that the following are true: does not intend to reside permanently in the United States; has substantially complied with the immigration laws and requirements relating to his or her student nonimmigrant status; has not taken any steps to change his nonimmigrant status in the United States toward becoming a permanent resident of the United States; and has a closer connection to a foreign country than to the United States as evidenced by the factors listed in Treasury Regulation 301.7701(b)-2(d)(1).
During 2024, did you apply for, or take other affirmative steps to apply for, lawful permanent resident status in the United States or have an application pending to change your status to that of a lawful permanent resident of the United States?	The IRS uses this information to determine whether the student is taking any steps to become a permanent resident and whether the student is still entitled to treaty benefits.

Completing Form 8843 70

Summary

Foreign scholars or students and their nonresident spouse/dependents (including young children) must complete Form 8843, even if they had no income. Form 8843 asks for information on:

• Why the student or scholar is in this country

• The student’s educational institution

Generally:

• Students complete Parts I and III of Form 8843

• Scholars complete Parts I and II of Form 8843

• Filers who complete Parts IV and V should be referred to a professional tax preparer (Out of Scope)

The Form 8843 can be electronically filed with the Form 1040-NR. For those not required to file a Form 1040NR, a paper Form 8843 must be mailed to the Internal Revenue Service Center in Austin, TX by the due date for the Form 1040-NR.

Marguerite Bernard, a citizen of France, came to the U.S. on F-1 immigration status to attend The University, 80 East Broadway, Anytown, SC 29000. She had never been to the U.S. before arriving here on August 10, 2021.

Her academic director is Dr. Moore. Dr. Moore uses the same address as the college and his phone number is (999) 444-4444.

Marguerite’s Social Security number is XXX-00-XXXX, and she had no income. Her visa number is 17318842. Her passport number is 4321002017.

Marguerite’s home address is: 23 Rue Bonaparte, Bondy, France

Her address in the U.S. is: 324 East Broadway, Anytown, SC 29000

Her academic director is Dr. Moore. Dr. Moore uses the same address as the college and his phone number is (999) 444-4444.

Complete Marguerite’s Form 8843, based on the facts provided.

Completing Form 8843 71

Based on the information given, Marguerite needs to complete Form 8843 for 2024.

Completing Form 8843 72

Completing Form 8843 73

EXERCISES (continued)

Question 2

True or False? Scholars and students must file Form 8843 if they have excludable days of presence from the substantial presence test.

Question 3

True or False? Canadian students who are exempt individuals do not need to complete Form 8843 if they do not have a visa.

Question 4

True or False? When asked to enter the actual number of days they were present in the U.S. during the past 3 years, taxpayers may estimate the number of days they were in the U.S.

Question 5

Carolina de Moraes is a Brazilian student who came to the U.S to study international business at the University of South Carolina in Columbia. She spent most of the year there and then transferred to Georgetown University in Washington, DC. On her way to Washington, DC, she participated in the summer microbusiness workshop at The University of North Carolina at Chapel Hill. Which school’s information should she record when asked to enter the name, address, and telephone number of the academic institution she attended during the tax year?

• University of South Carolina at Columbia Georgetown University

• University of South Carolina at Columbia and Georgetown University

• University of South Carolina, University of North Carolina, and Georgetown University

Conclusion

EXERCISE Answers

Answer 1. B, Dr. Mueller was employed or trained under the direction of Dr. Heilreich, so he must record the

contact information for Dr. Heilreich on the line.

Answer 2. True, Days of presence that are excludable from the substantial presence test must be filed on

Form 8843.

Answer 3. False, If Canadian students are exempt individuals and do not have a visa, use the information

from their work authorization papers to complete Form 8843.

Answer 4. False, Taxpayers must count the actual number of days they were in the U.S.

Answer 5. B, Students who attend more than one academic institution during the year should report the one

they attended at the end of the year.

Completing Form 8843 74

Foreign Student Comprehensive Practice

Introduction

This lesson will help you prepare for the Link & Learn Taxes Foreign Student Test which you must successfully complete at an overall 80% proficiency to earn VITA/TCE certification.

Note: Due to the production schedule for this material, prior year or draft forms may be used in examples. The draft forms should never be used for actual tax preparation. Final forms are available on https://apps.irs.gov/app/ picklist/list/formsPublications.html in the tax preparation software, in the instruction booklet (e.g., Form 1040-NR Instructions), or in other publications.

Objectives

At the end of this lesson, you will be able to:

• Determine if a taxpayer is a resident or nonresident alien

• Identify the filing requirements for nonresident student taxpayers

• Determine whether a nonresident alien should file a tax return

• Identify which [other] forms a student should file [i.e., Forms 8843, Statement for Exempt Individuals and Individuals with a Medical Condition and 8233, Exemption From Withholding on Compensation for Independent (and Certain Dependent) Personal Services of a Nonresident Alien Individual]

• Determine a student’s filing status

• Determine what sources of income must be reported on tax returns

• Determine which tax treaty benefits a student is eligible for

• Determine which income code to use in the application of the treaty benefits

• Determine the source of a student’s or scholar’s income

• Identify any exemptions a student may have

• Accurately complete Form 1040-NR, U.S. Nonresident Alien Income Tax Return

• Identify foreign students and scholars who are exempt from Social Security and Medicare or self-employment taxes

• Accurately complete Form 8843

What will I learn?

In this lesson you will apply much of what you learned in the Foreign Student course. You will prepare tax returns for two foreign students and one Form 8843 and answer questions about their returns.

Taxpayer Overview – Part I: Simone Dupont

Our first taxpayer is Simone Dupont. Here is basic information about her:

What do I need?

• Form 1040-NR, U.S. Nonresident Alien Income

• Form 1042-S, Foreign Person’s U.S. Source Income Subject to Withholding

• Form 13614-NR, Nonresident Alien Intake and Interview Sheet

• Form 8233, Exemption from Withholding on Compensation for Independent (& Certain Dependent) Personal Service of a Nonresident Alien Individual

• Form 8843, Statement for Exempt Individuals and Individuals with a Medical Condition

• Form W-2, Wage and Tax Statement

• Publication 17, Your Federal Income Tax (For Individuals)

• Publication 4011, VITA/TCE Foreign Student and Scholar Volunteer Resource Guide

• Publication 5876, VITA/TCE Foreign Student and Scholar Volunteer Training Guide

Optional:

• Publication 4299, Privacy, Confidentiality, and Civil Rights - A Public Trust

• She was born April 15, 2003. She is a citizen and permanent resident of France and is single. Her address in her home country is 27 Rue Pasteur, Cabourg 14390, France. She came to the United States in F-1 immigration status on August 1, 2022. She has remained in this country ever since and is a full-time student at the local university.

• Simone began working on the university campus on January 3, 2023. She filed Form 8233 with the payroll department on January 15, 2023, advising the university to not withhold taxes. She earned $12,225 in wages.

Foreign Student Comprehensive Practice 75

• Simone received a scholarship that covered her room and board of $14,500 for the year. Simone will claim a treaty exemption for this amount. She received a Form 1042-S for this.

• Simone purchased ABC stock on November 2, 2021 for $200 and sold the stock September 5, 2023 for $800. Simone meets all the requirements of the United States-France Income Tax Treaty - Article 13(6).

• She did not have to pay income tax in France on her U.S. earnings. She did not take any affirmative steps to apply for permanent residence in the United States.

• If Simone must submit a return, she wants any refund mailed to her. She does not want to authorize anyone else to discuss the return with the IRS.

Foreign Student Comprehensive Practice 76

Foreign Student Comprehensive Practice 77

Foreign Student Comprehensive Practice 78

Foreign Student Comprehensive Practice 79

1042-S Foreign Person’s U.S. Source Income Subject to Withholding 2024 OMB No. 1545-0096
Form Go to www.irs.gov/Form1042S for instructions and the latest information. Copy A for
Department of the Treasury
Internal Revenue Service 0 1 2 3 4 5 6 7 8 9 UNIQUE FORM IDENTIFIER AMENDED AMENDMENT NO. Internal Revenue Servic
1 Income 2 Gross income 3 Chapter indicator. Enter “3” or “4” 3 13e Recipient’s U.S. TIN, if any 13f Ch. 3 status code 16
code
3a Exemption code 04 4a Exemption code XXX-XX-XXXX 13g Ch. 4 status code
16 14500 3b Tax rate 0. 00 4b Tax rate . 13h Recipient’s GIIN 13i Recipient’s foreign tax identification 13j LOB c
number, if any
5 Withholding allowance
6 Net income 14500
7a Federal tax withheld 13k Recipient’s account number
7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) . . . . . . 13l Recipient’s date of birth (YYYYMMDD)
7c Check if withholding occurred in subsequent year with respect to a 2 0 0 3 0 4 1 5
partnership interest . . . . . . . . . . . . . .
8 Tax withheld by other agents 14a Primary Withholding Agent’s Name (if applicable)
9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( ) 14b Primary Withholding Agent’s EIN
15 Check if pro-rata basis reporting
10 Total withholding credit (combine boxes 7a, 8, and 9)
15a Intermediary or flow-through entity’s EIN, if any 15b Ch. 3 status code 15c Ch. 4 status
11 Tax paid by withholding agent (amounts not withheld) (see instructions)
15d Intermediary or flow-through entity’s name
12a Withholding agent’s EIN 12b Ch. 3 status code 12c Ch. 4 status code
XX-XXXXXXX 02 15e Intermediary or flow-through entity’s GIIN
12d Withholding agent’s name 15f Country code 15g Foreign tax identification number, if any
12e Withholding agent’s Global Intermediary Identification Number (GIIN) 15h Address (number and street)
12f Country code 12g Foreign tax identification number, if any 15i City or town, state or province, country, ZIP or foreign postal code
12h Address (number and street) 16a Payer’s name 16b Payer’s TIN
221 WHITNEY AVENUE
12i City or town, state or province, country, ZIP or foreign postal code 16c Payer’s GIIN 16d Ch. 3 status code 16e Ch. 4 status c
YOUR TOWN, YS XXXXX
13a Recipient’s name 13b Recipient’s country code 17a State income tax withheld 17b Payer’s state tax no. 17c Name of stat
SIMONE DUPONT
13c Address (number and street)
250 CHURCH STREET
13d City or town, state or province, country, ZIP or foreign postal code
YOUR TOWN YS XXXXX

Form1042-S
Department of the Treasury
Internal Revenue Service
Foreign Person’s U.S. Source Income Subject to Withholding
Go to_www.irs.gov/Form1042S_for instructions and the latest information. 2024
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
OMB No. 1545-0096
Copy Afor
Internal Revenue Servic
1 Income
code
2Gross income3 Chapter indicator. Enter “3” or “4”
3a Exemption code
3b Tax rate
.
4a Exemption code
4b Tax rate
.
5Withholding allowance
6Net 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)
12aWithholding agent’s EIN
12b Ch. 3 status code
**12c **Ch. 4 status code
12dWithholding agent’s name
12eWithholding agent’s Global Intermediary Identification Number (GIIN)
12fCountry code
12gForeign tax identification number, if any
12hAddress (number and street)
12iCity or town, state or province, country, ZIP or foreign postal code
13aRecipient’s name
13b Recipient’s country code
13cAddress (number and street)
13dCity or town, state or province, country, ZIP or foreign postal code
13eRecipient’s U.S. TIN, if any
13fCh. 3 status code
13gCh. 4 status code
13hRecipient’s GIIN
13iRecipient’s foreign tax identification
number, if any
13jLOB c
13kRecipient’s account number
13l Recipient’s date of birth (YYYYMMDD)
14a Primary Withholding Agent’s Name (if applicable)
14bPrimary 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
**15d **Intermediary or flow-through entity’s name
**15e **Intermediary or flow-through entity’s GIIN
15fCountry code
15gForeign tax identification number, if any
15hAddress (number and street)
15iCity or town, state or province, country, ZIP or foreign postal code
16aPayer’s name
16bPayer’s TIN
16cPayer’s GIIN
16dCh. 3 status code
16eCh. 4 status c
17aState income tax withheld
17bPayer’s state tax no.
17cName of stat
0
1 2 3 4 5 6
7 8 9
16
14500
3
04
0
00
14500

XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|Form1042-S
Department of the Treasury
Internal Revenue Service
Foreign Person’s U.S. Source Income Subject to Withholding
Go to_www.irs.gov/Form1042S_for instructions and the latest information. 2024
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
OMB No. 1545-0096
Copy Afor
Internal Revenue Servic
1 Income
code
2Gross income3 Chapter indicator. Enter “3” or “4”
3a Exemption code
3b Tax rate
.
4a Exemption code
4b Tax rate
.
5Withholding allowance
6Net 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)
12aWithholding agent’s EIN
12b Ch. 3 status code
**12c **Ch. 4 status code
12dWithholding agent’s name
12eWithholding agent’s Global Intermediary Identification Number (GIIN)
12fCountry code
12gForeign tax identification number, if any
12hAddress (number and street)
12iCity or town, state or province, country, ZIP or foreign postal code
13aRecipient’s name
13b Recipient’s country code
13cAddress (number and street)
13dCity or town, state or province, country, ZIP or foreign postal code
13eRecipient’s U.S. TIN, if any
13fCh. 3 status code
13gCh. 4 status code
13hRecipient’s GIIN
13iRecipient’s foreign tax identification
number, if any
13jLOB c
13kRecipient’s account number
13l Recipient’s date of birth (YYYYMMDD)
14a Primary Withholding Agent’s Name (if applicable)
14bPrimary 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
**15d **Intermediary or flow-through entity’s name
**15e **Intermediary or flow-through entity’s GIIN
15fCountry code
15gForeign tax identification number, if any
15hAddress (number and street)
15iCity or town, state or province, country, ZIP or foreign postal code
16aPayer’s name
16bPayer’s TIN
16cPayer’s GIIN

16dCh. 3 status code
16eCh. 4 status c
17aState income tax withheld
17bPayer’s state tax no.
17cName of stat
0
1 2 3 4 5 6
7 8 9
16
14500
3
04
0
00
14500
XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|Form1042-S
Department of the Treasury
Internal Revenue Service
Foreign Person’s U.S. Source Income Subject to Withholding
Go to_www.irs.gov/Form1042S_for instructions and the latest information. 2024
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
OMB No. 1545-0096
Copy Afor
Internal Revenue Servic
1 Income
code
2Gross income3 Chapter indicator. Enter “3” or “4”
3a Exemption code
3b Tax rate
.
4a Exemption code
4b Tax rate
.
5Withholding allowance
6Net 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)
12aWithholding agent’s EIN
12b Ch. 3 status code
**12c **Ch. 4 status code
12dWithholding agent’s name
12eWithholding agent’s Global Intermediary Identification Number (GIIN)
12fCountry code
12gForeign tax identification number, if any
12hAddress (number and street)
12iCity or town, state or province, country, ZIP or foreign postal code
13aRecipient’s name
13b Recipient’s country code
13cAddress (number and street)
13dCity or town, state or province, country, ZIP or foreign postal code
13eRecipient’s U.S. TIN, if any
13fCh. 3 status code
13gCh. 4 status code
13hRecipient’s GIIN
13iRecipient’s foreign tax identification
number, if any
13jLOB c
13kRecipient’s account number
13l Recipient’s date of birth (YYYYMMDD)
14a Primary Withholding Agent’s Name (if applicable)
14bPrimary 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
**15d **Intermediary or flow-through entity’s name
**15e **Intermediary or flow-through entity’s GIIN

15fCountry code
15gForeign tax identification number, if any
15hAddress (number and street)
15iCity or town, state or province, country, ZIP or foreign postal code
16aPayer’s name
16bPayer’s TIN
16cPayer’s GIIN
16dCh. 3 status code
16eCh. 4 status c
17aState income tax withheld
17bPayer’s state tax no.
17cName of stat
0
1 2 3 4 5 6
7 8 9
16
14500
3
04
0
00
14500
XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|Form1042-S
Department of the Treasury
Internal Revenue Service
Foreign Person’s U.S. Source Income Subject to Withholding
Go to_www.irs.gov/Form1042S_for instructions and the latest information. 2024
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
OMB No. 1545-0096
Copy Afor
Internal Revenue Servic
1 Income
code
2Gross income3 Chapter indicator. Enter “3” or “4”
3a Exemption code
3b Tax rate
.
4a Exemption code
4b Tax rate
.
5Withholding allowance
6Net 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)
12aWithholding agent’s EIN
12b Ch. 3 status code
**12c **Ch. 4 status code
12dWithholding agent’s name
12eWithholding agent’s Global Intermediary Identification Number (GIIN)
12fCountry code
12gForeign tax identification number, if any
12hAddress (number and street)
12iCity or town, state or province, country, ZIP or foreign postal code
13aRecipient’s name
13b Recipient’s country code
13cAddress (number and street)
13dCity or town, state or province, country, ZIP or foreign postal code
13eRecipient’s U.S. TIN, if any
13fCh. 3 status code
13gCh. 4 status code
13hRecipient’s GIIN
13iRecipient’s foreign tax identification
number, if any
13jLOB c
13kRecipient’s account number
13l Recipient’s date of birth (YYYYMMDD)
14a Primary Withholding Agent’s Name (if applicable)
14bPrimary 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
15d Intermediary or flow-through entity’s name
15e Intermediary or flow-through entity’s GIIN
15fCountry code
15gForeign tax identification number, if any
15hAddress (number and street)
15iCity or town, state or province, country, ZIP or foreign postal code
16aPayer’s name
16bPayer’s TIN
16cPayer’s GIIN
16dCh. 3 status code
16eCh. 4 status c
17aState income tax withheld
17bPayer’s state tax no.
17cName of stat
0
1 2 3 4 5 6
7 8 9
16
14500
3
04
0
00
14500
XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|Form1042-S
Department of the Treasury
Internal Revenue Service
Foreign Person’s U.S. Source Income Subject to Withholding
Go to_www.irs.gov/Form1042S_for instructions and the latest information. 2024
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
OMB No. 1545-0096
Copy Afor
Internal Revenue Servic
1 Income
code
2Gross income3 Chapter indicator. Enter “3” or “4”
3a Exemption code
3b Tax rate
.
4a Exemption code
4b Tax rate
.
5Withholding allowance
6Net 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)
12aWithholding agent’s EIN
12b Ch. 3 status code
**12c **Ch. 4 status code
12dWithholding agent’s name
12eWithholding agent’s Global Intermediary Identification Number (GIIN)
12fCountry code
12gForeign tax identification number, if any
12hAddress (number and street)
12iCity or town, state or province, country, ZIP or foreign postal code
13aRecipient’s name
13b Recipient’s country code
13cAddress (number and street)
13dCity or town, state or province, country, ZIP or foreign postal code
13eRecipient’s U.S. TIN, if any
13fCh. 3 status code
13gCh. 4 status code
13hRecipient’s GIIN

13iRecipient’s foreign tax identification
number, if any
13jLOB c
13kRecipient’s account number
13l Recipient’s date of birth (YYYYMMDD)
14a Primary Withholding Agent’s Name (if applicable)
14bPrimary 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
15d Intermediary or flow-through entity’s name
15e Intermediary or flow-through entity’s GIIN
15fCountry code
15gForeign tax identification number, if any
15hAddress (number and street)
15iCity or town, state or province, country, ZIP or foreign postal code
16aPayer’s name
16bPayer’s TIN
16cPayer’s GIIN
16dCh. 3 status code
16eCh. 4 status c
17aState income tax withheld
17bPayer’s state tax no.
17cName of stat
0
1 2 3 4 5 6
7 8 9
16
14500
3
04
0
00
14500
XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|Form1042-S
Department of the Treasury
Internal Revenue Service
Foreign Person’s U.S. Source Income Subject to Withholding
Go to_www.irs.gov/Form1042S_for instructions and the latest information. 2024
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
OMB No. 1545-0096
Copy Afor
Internal Revenue Servic
1 Income
code
2Gross income3 Chapter indicator. Enter “3” or “4”
3a Exemption code
3b Tax rate
.
4a Exemption code
4b Tax rate
.
5Withholding allowance
6Net 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)
12aWithholding agent’s EIN
12b Ch. 3 status code
**12c **Ch. 4 status code
12dWithholding agent’s name
12eWithholding agent’s Global Intermediary Identification Number (GIIN)
12fCountry code
12gForeign tax identification number, if any
12hAddress (number and street)
12iCity or town, state or province, country, ZIP or foreign postal code
13aRecipient’s name

13b Recipient’s country code
13cAddress (number and street)
13dCity or town, state or province, country, ZIP or foreign postal code
13eRecipient’s U.S. TIN, if any
13fCh. 3 status code
13gCh. 4 status code
13hRecipient’s GIIN
13iRecipient’s foreign tax identification
number, if any
13jLOB c
13kRecipient’s account number
13l Recipient’s date of birth (YYYYMMDD)
14a Primary Withholding Agent’s Name (if applicable)
14bPrimary 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
15d Intermediary or flow-through entity’s name
15e Intermediary or flow-through entity’s GIIN
15fCountry code
15gForeign tax identification number, if any
15hAddress (number and street)
15iCity or town, state or province, country, ZIP or foreign postal code
16aPayer’s name
16bPayer’s TIN
16cPayer’s GIIN
16dCh. 3 status code
16eCh. 4 status c
17aState income tax withheld
17bPayer’s state tax no.
17cName of stat
0
1 2 3 4 5 6
7 8 9
16
14500
3
04
0
00
14500
XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|Form1042-S
Department of the Treasury
Internal Revenue Service
Foreign Person’s U.S. Source Income Subject to Withholding
Go to_www.irs.gov/Form1042S_for instructions and the latest information. 2024
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
OMB No. 1545-0096
Copy Afor
Internal Revenue Servic
1 Income
code
2Gross income3 Chapter indicator. Enter “3” or “4”
3a Exemption code
3b Tax rate
.
4a Exemption code
4b Tax rate
.
5Withholding allowance
6Net 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)
12aWithholding agent’s EIN
12b Ch. 3 status code
**12c **Ch. 4 status code
12dWithholding agent’s name

12eWithholding agent’s Global Intermediary Identification Number (GIIN)
12fCountry code
12gForeign tax identification number, if any
12hAddress (number and street)
12iCity or town, state or province, country, ZIP or foreign postal code
13aRecipient’s name
13b Recipient’s country code
13cAddress (number and street)
13dCity or town, state or province, country, ZIP or foreign postal code
13eRecipient’s U.S. TIN, if any
13fCh. 3 status code
13gCh. 4 status code
13hRecipient’s GIIN
13iRecipient’s foreign tax identification
number, if any
13jLOB c
13kRecipient’s account number
13l Recipient’s date of birth (YYYYMMDD)
14a Primary Withholding Agent’s Name (if applicable)
14bPrimary 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
15d Intermediary or flow-through entity’s name
15e Intermediary or flow-through entity’s GIIN
15fCountry code
15gForeign tax identification number, if any
15hAddress (number and street)
15iCity or town, state or province, country, ZIP or foreign postal code
16aPayer’s name
16bPayer’s TIN
16cPayer’s GIIN
16dCh. 3 status code
16eCh. 4 status c
17aState income tax withheld
17bPayer’s state tax no.
17cName of stat
0
1 2 3 4 5 6
7 8 9
16
14500
3
04
0
00
14500
XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|Form1042-S
Department of the Treasury
Internal Revenue Service
Foreign Person’s U.S. Source Income Subject to Withholding
Go to_www.irs.gov/Form1042S_for instructions and the latest information. 2024
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
OMB No. 1545-0096
Copy Afor
Internal Revenue Servic
1 Income
code
2Gross income3 Chapter indicator. Enter “3” or “4”
3a Exemption code
3b Tax rate
.
4a Exemption code
4b Tax rate
.
5Withholding allowance
6Net 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)
12aWithholding agent’s EIN
12b Ch. 3 status code
**12c **Ch. 4 status code
12dWithholding agent’s name
12eWithholding agent’s Global Intermediary Identification Number (GIIN)
12fCountry code
12gForeign tax identification number, if any
12hAddress (number and street)
12iCity or town, state or province, country, ZIP or foreign postal code
13aRecipient’s name
13b Recipient’s country code
13cAddress (number and street)
13dCity or town, state or province, country, ZIP or foreign postal code
13eRecipient’s U.S. TIN, if any
13fCh. 3 status code
13gCh. 4 status code
13hRecipient’s GIIN
13iRecipient’s foreign tax identification
number, if any
13jLOB c
13kRecipient’s account number
13l Recipient’s date of birth (YYYYMMDD)
14a Primary Withholding Agent’s Name (if applicable)
14bPrimary 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
15d Intermediary or flow-through entity’s name
15e Intermediary or flow-through entity’s GIIN
15fCountry code
15gForeign tax identification number, if any
15hAddress (number and street)
15iCity or town, state or province, country, ZIP or foreign postal code
16aPayer’s name
16bPayer’s TIN
16cPayer’s GIIN
16dCh. 3 status code
16eCh. 4 status c
17aState income tax withheld
17bPayer’s state tax no.
17cName of stat
0
1 2 3 4 5 6
7 8 9
16
14500
3
04
0
00
14500
XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|Form1042-S
Department of the Treasury
Internal Revenue Service
Foreign Person’s U.S. Source Income Subject to Withholding
Go to_www.irs.gov/Form1042S_for instructions and the latest information. 2024
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
OMB No. 1545-0096
Copy Afor
Internal Revenue Servic
1 Income
code
2Gross income3 Chapter indicator. Enter “3” or “4”
3a Exemption code
3b Tax rate
.
4a Exemption code
4b Tax rate
.
5Withholding allowance
6Net 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)
12aWithholding agent’s EIN
12b Ch. 3 status code
**12c **Ch. 4 status code
12dWithholding agent’s name
12eWithholding agent’s Global Intermediary Identification Number (GIIN)
12fCountry code
12gForeign tax identification number, if any
12hAddress (number and street)
12iCity or town, state or province, country, ZIP or foreign postal code
13aRecipient’s name
13b Recipient’s country code
13cAddress (number and street)
13dCity or town, state or province, country, ZIP or foreign postal code
13eRecipient’s U.S. TIN, if any
13fCh. 3 status code
13gCh. 4 status code
13hRecipient’s GIIN
13iRecipient’s foreign tax identification
number, if any
13jLOB c
13kRecipient’s account number
13l Recipient’s date of birth (YYYYMMDD)
14a Primary Withholding Agent’s Name (if applicable)
14bPrimary 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
15d Intermediary or flow-through entity’s name
15e Intermediary or flow-through entity’s GIIN
15fCountry code
15gForeign tax identification number, if any
15hAddress (number and street)
15iCity or town, state or province, country, ZIP or foreign postal code
16aPayer’s name
16bPayer’s TIN
16cPayer’s GIIN
16dCh. 3 status code
16eCh. 4 status c
17aState income tax withheld
17bPayer’s state tax no.
17cName of stat
0
1 2 3 4 5 6
7 8 9
16
14500
3
04
0
00
14500
XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|Form1042-S
Department of the Treasury
Internal Revenue Service
Foreign Person’s U.S. Source Income Subject to Withholding
Go to_www.irs.gov/Form1042S_for instructions and the latest information. 2024
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
OMB No. 1545-0096
Copy Afor
Internal Revenue Servic
1 Income
code
2Gross income3 Chapter indicator. Enter “3” or “4”
3a Exemption code
3b Tax rate
.
4a Exemption code
4b Tax rate
.
5Withholding allowance
6Net 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)
12aWithholding agent’s EIN
12b Ch. 3 status code
**12c **Ch. 4 status code
12dWithholding agent’s name
12eWithholding agent’s Global Intermediary Identification Number (GIIN)
12fCountry code
12gForeign tax identification number, if any
12hAddress (number and street)
12iCity or town, state or province, country, ZIP or foreign postal code
13aRecipient’s name
13b Recipient’s country code
13cAddress (number and street)
13dCity or town, state or province, country, ZIP or foreign postal code
13eRecipient’s U.S. TIN, if any
13fCh. 3 status code
13gCh. 4 status code
13hRecipient’s GIIN
13iRecipient’s foreign tax identification
number, if any
13jLOB c
13kRecipient’s account number
13l Recipient’s date of birth (YYYYMMDD)
14a Primary Withholding Agent’s Name (if applicable)
14bPrimary 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
15d Intermediary or flow-through entity’s name
15e Intermediary or flow-through entity’s GIIN
15fCountry code
15gForeign tax identification number, if any
15hAddress (number and street)
15iCity or town, state or province, country, ZIP or foreign postal code
16aPayer’s name
16bPayer’s TIN
16cPayer’s GIIN
16dCh. 3 status code
16eCh. 4 status c
17aState income tax withheld
17bPayer’s state tax no.
17cName of stat
0
1 2 3 4 5 6
7 8 9
16
14500
3
04
0
00
14500
XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|Form1042-S
Department of the Treasury
Internal Revenue Service
Foreign Person’s U.S. Source Income Subject to Withholding
Go to_www.irs.gov/Form1042S_for instructions and the latest information. 2024
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
OMB No. 1545-0096
Copy Afor
Internal Revenue Servic
**1 **Income

code
2Gross income3 Chapter indicator. Enter “3” or “4”
3a Exemption code
3b Tax rate
.
4a Exemption code
4b Tax rate
.
5Withholding allowance
6Net 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)
12aWithholding agent’s EIN
12b Ch. 3 status code
**12c **Ch. 4 status code
12dWithholding agent’s name
12eWithholding agent’s Global Intermediary Identification Number (GIIN)
12fCountry code
12gForeign tax identification number, if any
12hAddress (number and street)
12iCity or town, state or province, country, ZIP or foreign postal code
13aRecipient’s name
13b Recipient’s country code
13cAddress (number and street)
13dCity or town, state or province, country, ZIP or foreign postal code
13eRecipient’s U.S. TIN, if any
13fCh. 3 status code
13gCh. 4 status code
13hRecipient’s GIIN
13iRecipient’s foreign tax identification
number, if any
13jLOB c
13kRecipient’s account number
13l Recipient’s date of birth (YYYYMMDD)
14a Primary Withholding Agent’s Name (if applicable)
14bPrimary 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
**15d **Intermediary or flow-through entity’s name
15e Intermediary or flow-through entity’s GIIN
15fCountry code
15gForeign tax identification number, if any
15hAddress (number and street)
15iCity or town, state or province, country, ZIP or foreign postal code
16aPayer’s name
16bPayer’s TIN
16cPayer’s GIIN
16dCh. 3 status code
16eCh. 4 status c
17aState income tax withheld
17bPayer’s state tax no.
17cName of stat
0
1 2 3 4 5 6
7 8 9
16
14500
3
04
0
00
14500
XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|Form1042-S
Department of the Treasury
Internal Revenue Service

Foreign Person’s U.S. Source Income Subject to Withholding
Go to_www.irs.gov/Form1042S_for instructions and the latest information. 2024
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
OMB No. 1545-0096
Copy Afor
Internal Revenue Servic
1 Income
code
2Gross income3 Chapter indicator. Enter “3” or “4”
3a Exemption code
3b Tax rate
.
4a Exemption code
4b Tax rate
.
5Withholding allowance
6Net 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)
12aWithholding agent’s EIN
12b Ch. 3 status code
**12c **Ch. 4 status code
12dWithholding agent’s name
12eWithholding agent’s Global Intermediary Identification Number (GIIN)
12fCountry code
12gForeign tax identification number, if any
12hAddress (number and street)
12iCity or town, state or province, country, ZIP or foreign postal code
13aRecipient’s name
13b Recipient’s country code
13cAddress (number and street)
13dCity or town, state or province, country, ZIP or foreign postal code
13eRecipient’s U.S. TIN, if any
13fCh. 3 status code
13gCh. 4 status code
13hRecipient’s GIIN
13iRecipient’s foreign tax identification
number, if any
13jLOB c
13kRecipient’s account number
13l Recipient’s date of birth (YYYYMMDD)
14a Primary Withholding Agent’s Name (if applicable)
14bPrimary 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
**15d **Intermediary or flow-through entity’s name
**15e **Intermediary or flow-through entity’s GIIN
15fCountry code
15gForeign tax identification number, if any
15hAddress (number and street)
15iCity or town, state or province, country, ZIP or foreign postal code
16aPayer’s name
16bPayer’s TIN
16cPayer’s GIIN
16dCh. 3 status code
16eCh. 4 status c
17aState income tax withheld
17bPayer’s state tax no.
17cName of stat
0
1 2 3 4 5 6
7 8 9
16
14500
3
04
0
00
14500
XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX

SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|Form1042-S
Department of the Treasury
Internal Revenue Service
Foreign Person’s U.S. Source Income Subject to Withholding
Go to_www.irs.gov/Form1042S_for instructions and the latest information. 2024
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
OMB No. 1545-0096
Copy Afor
Internal Revenue Servic
1 Income
code
2Gross income3 Chapter indicator. Enter “3” or “4”
3a Exemption code
3b Tax rate
.
4a Exemption code
4b Tax rate
.
5Withholding allowance
6Net 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)
12aWithholding agent’s EIN
12b Ch. 3 status code
**12c **Ch. 4 status code
12dWithholding agent’s name
12eWithholding agent’s Global Intermediary Identification Number (GIIN)
12fCountry code
12gForeign tax identification number, if any
12hAddress (number and street)
12iCity or town, state or province, country, ZIP or foreign postal code
13aRecipient’s name
13b Recipient’s country code
13cAddress (number and street)
13dCity or town, state or province, country, ZIP or foreign postal code
13eRecipient’s U.S. TIN, if any
13fCh. 3 status code
13gCh. 4 status code
13hRecipient’s GIIN
13iRecipient’s foreign tax identification
number, if any
13jLOB c
13kRecipient’s account number
13l Recipient’s date of birth (YYYYMMDD)
14a Primary Withholding Agent’s Name (if applicable)
14bPrimary 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
**15d **Intermediary or flow-through entity’s name
**15e **Intermediary or flow-through entity’s GIIN
15fCountry code
15gForeign tax identification number, if any
15hAddress (number and street)
15iCity or town, state or province, country, ZIP or foreign postal code
16aPayer’s name
16bPayer’s TIN
16cPayer’s GIIN
16dCh. 3 status code
16eCh. 4 status c
17aState income tax withheld

17bPayer’s state tax no.
17cName of stat
0
1 2 3 4 5 6
7 8 9
16
14500
3
04
0
00
14500
XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|Form1042-S
Department of the Treasury
Internal Revenue Service
Foreign Person’s U.S. Source Income Subject to Withholding
Go to_www.irs.gov/Form1042S_for instructions and the latest information. 2024
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
OMB No. 1545-0096
Copy Afor
Internal Revenue Servic
1 Income
code
2Gross income3 Chapter indicator. Enter “3” or “4”
3a Exemption code
3b Tax rate
.
4a Exemption code
4b Tax rate
.
5Withholding allowance
6Net 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)
12aWithholding agent’s EIN
12b Ch. 3 status code
**12c **Ch. 4 status code
12dWithholding agent’s name
12eWithholding agent’s Global Intermediary Identification Number (GIIN)
12fCountry code
12gForeign tax identification number, if any
12hAddress (number and street)
12iCity or town, state or province, country, ZIP or foreign postal code
13aRecipient’s name
13b Recipient’s country code
13cAddress (number and street)
13dCity or town, state or province, country, ZIP or foreign postal code
13eRecipient’s U.S. TIN, if any
13fCh. 3 status code
13gCh. 4 status code
13hRecipient’s GIIN
13iRecipient’s foreign tax identification
number, if any
13jLOB c
13kRecipient’s account number
13l Recipient’s date of birth (YYYYMMDD)
14a Primary Withholding Agent’s Name (if applicable)
14bPrimary 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
**15d **Intermediary or flow-through entity’s name
**15e **Intermediary or flow-through entity’s GIIN
15fCountry code
15gForeign tax identification number, if any

15hAddress (number and street)
15iCity or town, state or province, country, ZIP or foreign postal code
16aPayer’s name
16bPayer’s TIN
16cPayer’s GIIN
16dCh. 3 status code
16eCh. 4 status c
17aState income tax withheld
17bPayer’s state tax no.
17cName of stat
0
1 2 3 4 5 6
7 8 9
16
14500
3
04
0
00
14500
XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|Form1042-S
Department of the Treasury
Internal Revenue Service
Foreign Person’s U.S. Source Income Subject to Withholding
Go to_www.irs.gov/Form1042S_for instructions and the latest information. 2024
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
OMB No. 1545-0096
Copy Afor
Internal Revenue Servic
1 Income
code
2Gross income3 Chapter indicator. Enter “3” or “4”
3a Exemption code
3b Tax rate
.
4a Exemption code
4b Tax rate
.
5Withholding allowance
6Net 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)
12aWithholding agent’s EIN
12b Ch. 3 status code
**12c **Ch. 4 status code
12dWithholding agent’s name
12eWithholding agent’s Global Intermediary Identification Number (GIIN)
12fCountry code
12gForeign tax identification number, if any
12hAddress (number and street)
12iCity or town, state or province, country, ZIP or foreign postal code
13aRecipient’s name
13b Recipient’s country code
13cAddress (number and street)
13dCity or town, state or province, country, ZIP or foreign postal code
13eRecipient’s U.S. TIN, if any
13fCh. 3 status code
13gCh. 4 status code
13hRecipient’s GIIN
13iRecipient’s foreign tax identification
number, if any
13jLOB c
13kRecipient’s account number
13l Recipient’s date of birth (YYYYMMDD)
14a Primary Withholding Agent’s Name (if applicable)
14bPrimary 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
15d Intermediary or flow-through entity’s name
15e Intermediary or flow-through entity’s GIIN
15fCountry code
15gForeign tax identification number, if any
15hAddress (number and street)
15iCity or town, state or province, country, ZIP or foreign postal code
16aPayer’s name
16bPayer’s TIN
16cPayer’s GIIN
16dCh. 3 status code
16eCh. 4 status c
17aState income tax withheld
17bPayer’s state tax no.
17cName of stat
0
1 2 3 4 5 6
7 8 9
16
14500
3
04
0
00
14500
XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|Form1042-S
Department of the Treasury
Internal Revenue Service
Foreign Person’s U.S. Source Income Subject to Withholding
Go to_www.irs.gov/Form1042S_for instructions and the latest information. 2024
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
OMB No. 1545-0096
Copy Afor
Internal Revenue Servic
1 Income
code
2Gross income3 Chapter indicator. Enter “3” or “4”
3a Exemption code
3b Tax rate
.
4a Exemption code
4b Tax rate
.
5Withholding allowance
6Net 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)
12aWithholding agent’s EIN
12b Ch. 3 status code
**12c **Ch. 4 status code
12dWithholding agent’s name
12eWithholding agent’s Global Intermediary Identification Number (GIIN)
12fCountry code
12gForeign tax identification number, if any
12hAddress (number and street)
12iCity or town, state or province, country, ZIP or foreign postal code
13aRecipient’s name
13b Recipient’s country code
13cAddress (number and street)
13dCity or town, state or province, country, ZIP or foreign postal code
13eRecipient’s U.S. TIN, if any
13fCh. 3 status code
13gCh. 4 status code
13hRecipient’s GIIN
13iRecipient’s foreign tax identification
number, if any

13jLOB c
13kRecipient’s account number
13l Recipient’s date of birth (YYYYMMDD)
14a Primary Withholding Agent’s Name (if applicable)
14bPrimary 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
15d Intermediary or flow-through entity’s name
15e Intermediary or flow-through entity’s GIIN
15fCountry code
15gForeign tax identification number, if any
15hAddress (number and street)
15iCity or town, state or province, country, ZIP or foreign postal code
16aPayer’s name
16bPayer’s TIN
16cPayer’s GIIN
16dCh. 3 status code
16eCh. 4 status c
17aState income tax withheld
17bPayer’s state tax no.
17cName of stat
0
1 2 3 4 5 6
7 8 9
16
14500
3
04
0
00
14500
XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|Form1042-S
Department of the Treasury
Internal Revenue Service
Foreign Person’s U.S. Source Income Subject to Withholding
Go to_www.irs.gov/Form1042S_for instructions and the latest information. 2024
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
OMB No. 1545-0096
Copy Afor
Internal Revenue Servic
1 Income
code
2Gross income3 Chapter indicator. Enter “3” or “4”
3a Exemption code
3b Tax rate
.
4a Exemption code
4b Tax rate
.
5Withholding allowance
6Net 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)
12aWithholding agent’s EIN
12b Ch. 3 status code
**12c **Ch. 4 status code
12dWithholding agent’s name
12eWithholding agent’s Global Intermediary Identification Number (GIIN)
12fCountry code
12gForeign tax identification number, if any
12hAddress (number and street)
12iCity or town, state or province, country, ZIP or foreign postal code
13aRecipient’s name
13b Recipient’s country code
13cAddress (number and street)

13dCity or town, state or province, country, ZIP or foreign postal code
13eRecipient’s U.S. TIN, if any
13fCh. 3 status code
13gCh. 4 status code
13hRecipient’s GIIN
13iRecipient’s foreign tax identification
number, if any
13jLOB c
13kRecipient’s account number
13l Recipient’s date of birth (YYYYMMDD)
14a Primary Withholding Agent’s Name (if applicable)
14bPrimary 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
15d Intermediary or flow-through entity’s name
15e Intermediary or flow-through entity’s GIIN
15fCountry code
15gForeign tax identification number, if any
15hAddress (number and street)
15iCity or town, state or province, country, ZIP or foreign postal code
16aPayer’s name
16bPayer’s TIN
16cPayer’s GIIN
16dCh. 3 status code
16eCh. 4 status c
17aState income tax withheld
17bPayer’s state tax no.
17cName of stat
0
1 2 3 4 5 6
7 8 9
16
14500
3
04
0
00
14500
XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|Form1042-S
Department of the Treasury
Internal Revenue Service
Foreign Person’s U.S. Source Income Subject to Withholding
Go to_www.irs.gov/Form1042S_for instructions and the latest information. 2024
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
OMB No. 1545-0096
Copy Afor
Internal Revenue Servic
1 Income
code
2Gross income3 Chapter indicator. Enter “3” or “4”
3a Exemption code
3b Tax rate
.
4a Exemption code
4b Tax rate
.
5Withholding allowance
6Net 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)
12aWithholding agent’s EIN
12b Ch. 3 status code
**12c **Ch. 4 status code
12dWithholding agent’s name
12eWithholding agent’s Global Intermediary Identification Number (GIIN)
12fCountry code

12gForeign tax identification number, if any
12hAddress (number and street)
12iCity or town, state or province, country, ZIP or foreign postal code
13aRecipient’s name
13b Recipient’s country code
13cAddress (number and street)
13dCity or town, state or province, country, ZIP or foreign postal code
13eRecipient’s U.S. TIN, if any
13fCh. 3 status code
13gCh. 4 status code
13hRecipient’s GIIN
13iRecipient’s foreign tax identification
number, if any
13jLOB c
13kRecipient’s account number
13l Recipient’s date of birth (YYYYMMDD)
14a Primary Withholding Agent’s Name (if applicable)
14bPrimary 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
15d Intermediary or flow-through entity’s name
15e Intermediary or flow-through entity’s GIIN
15fCountry code
15gForeign tax identification number, if any
15hAddress (number and street)
15iCity or town, state or province, country, ZIP or foreign postal code
16aPayer’s name
16bPayer’s TIN
16cPayer’s GIIN
16dCh. 3 status code
16eCh. 4 status c
17aState income tax withheld
17bPayer’s state tax no.
17cName of stat
0
1 2 3 4 5 6
7 8 9
16
14500
3
04
0
00
14500
XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|Form1042-S
Department of the Treasury
Internal Revenue Service
Foreign Person’s U.S. Source Income Subject to Withholding
Go to_www.irs.gov/Form1042S_for instructions and the latest information. 2024
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
OMB No. 1545-0096
Copy Afor
Internal Revenue Servic
1 Income
code
2Gross income3 Chapter indicator. Enter “3” or “4”
3a Exemption code
3b Tax rate
.
4a Exemption code
4b Tax rate
.
5Withholding allowance
6Net 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)
12aWithholding agent’s EIN
12b Ch. 3 status code
**12c **Ch. 4 status code
12dWithholding agent’s name
12eWithholding agent’s Global Intermediary Identification Number (GIIN)
12fCountry code
12gForeign tax identification number, if any
12hAddress (number and street)
12iCity or town, state or province, country, ZIP or foreign postal code
13aRecipient’s name
13b Recipient’s country code
13cAddress (number and street)
13dCity or town, state or province, country, ZIP or foreign postal code
13eRecipient’s U.S. TIN, if any
13fCh. 3 status code
13gCh. 4 status code
13hRecipient’s GIIN
13iRecipient’s foreign tax identification
number, if any
13jLOB c
13kRecipient’s account number
13l Recipient’s date of birth (YYYYMMDD)
14a Primary Withholding Agent’s Name (if applicable)
14bPrimary 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
15d Intermediary or flow-through entity’s name
15e Intermediary or flow-through entity’s GIIN
15fCountry code
15gForeign tax identification number, if any
15hAddress (number and street)
15iCity or town, state or province, country, ZIP or foreign postal code
16aPayer’s name
16bPayer’s TIN
16cPayer’s GIIN
16dCh. 3 status code
16eCh. 4 status c
17aState income tax withheld
17bPayer’s state tax no.
17cName of stat
0
1 2 3 4 5 6
7 8 9
16
14500
3
04
0
00
14500
XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|Form1042-S
Department of the Treasury
Internal Revenue Service
Foreign Person’s U.S. Source Income Subject to Withholding
Go to_www.irs.gov/Form1042S_for instructions and the latest information. 2024
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
OMB No. 1545-0096
Copy Afor
Internal Revenue Servic
1 Income
code
2Gross income3 Chapter indicator. Enter “3” or “4”
3a Exemption code
3b Tax rate
.
4a Exemption code
4b Tax rate
.
5Withholding allowance
6Net 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)
12aWithholding agent’s EIN
12b Ch. 3 status code
**12c **Ch. 4 status code
12dWithholding agent’s name
12eWithholding agent’s Global Intermediary Identification Number (GIIN)
12fCountry code
12gForeign tax identification number, if any
12hAddress (number and street)
12iCity or town, state or province, country, ZIP or foreign postal code
13aRecipient’s name
13b Recipient’s country code
13cAddress (number and street)
13dCity or town, state or province, country, ZIP or foreign postal code
13eRecipient’s U.S. TIN, if any
13fCh. 3 status code
13gCh. 4 status code
13hRecipient’s GIIN
13iRecipient’s foreign tax identification
number, if any
13jLOB c
13kRecipient’s account number
13l Recipient’s date of birth (YYYYMMDD)
14a Primary Withholding Agent’s Name (if applicable)
14bPrimary 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
15d Intermediary or flow-through entity’s name
15e Intermediary or flow-through entity’s GIIN
15fCountry code
15gForeign tax identification number, if any
15hAddress (number and street)
15iCity or town, state or province, country, ZIP or foreign postal code
16aPayer’s name
16bPayer’s TIN
16cPayer’s GIIN
16dCh. 3 status code
16eCh. 4 status c
17aState income tax withheld
17bPayer’s state tax no.
17cName of stat
0
1 2 3 4 5 6
7 8 9
16
14500
3
04
0
00
14500
XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|Form1042-S
Department of the Treasury
Internal Revenue Service
Foreign Person’s U.S. Source Income Subject to Withholding
Go to_www.irs.gov/Form1042S_for instructions and the latest information. 2024
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
OMB No. 1545-0096
Copy Afor
Internal Revenue Servic
1 Income
code
2Gross income3 Chapter indicator. Enter “3” or “4”
3a Exemption code
3b Tax rate
.
4a Exemption code
4b Tax rate
.
5Withholding allowance
6Net 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)
12aWithholding agent’s EIN
12b Ch. 3 status code
**12c **Ch. 4 status code
12dWithholding agent’s name
12eWithholding agent’s Global Intermediary Identification Number (GIIN)
12fCountry code
12gForeign tax identification number, if any
12hAddress (number and street)
12iCity or town, state or province, country, ZIP or foreign postal code
13aRecipient’s name
13b Recipient’s country code
13cAddress (number and street)
13dCity or town, state or province, country, ZIP or foreign postal code
13eRecipient’s U.S. TIN, if any
13fCh. 3 status code
13gCh. 4 status code
13hRecipient’s GIIN
13iRecipient’s foreign tax identification
number, if any
13jLOB c
13kRecipient’s account number
13l Recipient’s date of birth (YYYYMMDD)
14a Primary Withholding Agent’s Name (if applicable)
14bPrimary 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
15d Intermediary or flow-through entity’s name
15e Intermediary or flow-through entity’s GIIN
15fCountry code
15gForeign tax identification number, if any
15hAddress (number and street)
15iCity or town, state or province, country, ZIP or foreign postal code
16aPayer’s name
16bPayer’s TIN
16cPayer’s GIIN
16dCh. 3 status code
16eCh. 4 status c
17aState income tax withheld
17bPayer’s state tax no.
17cName of stat
0
1 2 3 4 5 6
7 8 9
16
14500
3
04
0
00
14500
XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|Form1042-S
Department of the Treasury
Internal Revenue Service
Foreign Person’s U.S. Source Income Subject to Withholding
Go to_www.irs.gov/Form1042S_for instructions and the latest information. 2024
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
OMB No. 1545-0096
Copy Afor
Internal Revenue Servic
1 Income
code
2Gross income3 Chapter indicator. Enter “3” or “4”

3a Exemption code
3b Tax rate
.
4a Exemption code
4b Tax rate
.
5Withholding allowance
6Net 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)
12aWithholding agent’s EIN
12b Ch. 3 status code
**12c **Ch. 4 status code
12dWithholding agent’s name
12eWithholding agent’s Global Intermediary Identification Number (GIIN)
12fCountry code
12gForeign tax identification number, if any
12hAddress (number and street)
12iCity or town, state or province, country, ZIP or foreign postal code
13aRecipient’s name
13b Recipient’s country code
13cAddress (number and street)
13dCity or town, state or province, country, ZIP or foreign postal code
13eRecipient’s U.S. TIN, if any
13fCh. 3 status code
13gCh. 4 status code
13hRecipient’s GIIN
13iRecipient’s foreign tax identification
number, if any
13jLOB c
13kRecipient’s account number
13l Recipient’s date of birth (YYYYMMDD)
14a Primary Withholding Agent’s Name (if applicable)
14bPrimary 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
**15d **Intermediary or flow-through entity’s name
15e Intermediary or flow-through entity’s GIIN
15fCountry code
15gForeign tax identification number, if any
15hAddress (number and street)
15iCity or town, state or province, country, ZIP or foreign postal code
16aPayer’s name
16bPayer’s TIN
16cPayer’s GIIN
16dCh. 3 status code
16eCh. 4 status c
17aState income tax withheld
17bPayer’s state tax no.
17cName of stat
0
1 2 3 4 5 6
7 8 9
16
14500
3
04
0
00
14500
XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|Form1042-S
Department of the Treasury
Internal Revenue Service
Foreign Person’s U.S. Source Income Subject to Withholding

Go to_www.irs.gov/Form1042S_for instructions and the latest information. 2024
UNIQUE FORM IDENTIFIER
AMENDED
AMENDMENT NO.
OMB No. 1545-0096
Copy Afor
Internal Revenue Servic
1 Income
code
2Gross income3 Chapter indicator. Enter “3” or “4”
3a Exemption code
3b Tax rate
.
4a Exemption code
4b Tax rate
.
5Withholding allowance
6Net income
7a Federal tax withheld
7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
.
.
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7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
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.
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)
12aWithholding agent’s EIN
12b Ch. 3 status code
**12c **Ch. 4 status code
12dWithholding agent’s name
12eWithholding agent’s Global Intermediary Identification Number (GIIN)
12fCountry code
12gForeign tax identification number, if any
12hAddress (number and street)
12iCity or town, state or province, country, ZIP or foreign postal code
13aRecipient’s name
13b Recipient’s country code
13cAddress (number and street)
13dCity or town, state or province, country, ZIP or foreign postal code
13eRecipient’s U.S. TIN, if any
13fCh. 3 status code
13gCh. 4 status code
13hRecipient’s GIIN
13iRecipient’s foreign tax identification
number, if any
13jLOB c
13kRecipient’s account number
13l Recipient’s date of birth (YYYYMMDD)
14a Primary Withholding Agent’s Name (if applicable)
14bPrimary 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
**15d **Intermediary or flow-through entity’s name
**15e **Intermediary or flow-through entity’s GIIN
15fCountry code
15gForeign tax identification number, if any
15hAddress (number and street)
15iCity or town, state or province, country, ZIP or foreign postal code
16aPayer’s name
16bPayer’s TIN
16cPayer’s GIIN
16dCh. 3 status code
16eCh. 4 status c
17aState income tax withheld
17bPayer’s state tax no.
17cName of stat
0
1 2 3 4 5 6
7 8 9
16
14500
3
04
0
00
14500
XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET

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
**15d **Intermediary or flow-through entity’s name
**15e **Intermediary or flow-through entity’s GIIN
15fCountry code
15gForeign tax identification number, if any
15hAddress (number and street)
15iCity or town, state or province, country, ZIP or foreign postal code
16aPayer’s name
16bPayer’s TIN
16cPayer’s GIIN
16dCh. 3 status code
16eCh. 4 status c
17aState income tax withheld
17bPayer’s state tax no.
17cName of stat
0
1 2 3 4 5 6
7 8 9
16
14500
3
04
0
00
14500
XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|0|**1 **|**2 **|**3 **|**3 **|**4 **|**5 **|**5 **|6|**7 **|**8 **|9|9|9|9|9|9|9|9|9|9|9|9|9|9|

XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because

escrow procedures were applied (see instructions) .
.
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
.
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
.
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
.
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.
.
.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
.
.
.
.
.|

XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
.
.
.
.
.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
.
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
.
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
.
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
.
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
.
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
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.|7b Check if federal tax withheld was not deposited with the IRS because
escrow procedures were applied (see instructions) .
.
.
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.
.|13l Recipient’s date of birth (YYYYMMDD)
2
0
0
3
0
4
1
5|13l Recipient’s date of birth (YYYYMMDD)
2
0
0
3
0
4
1
5|13l Recipient’s date of birth (YYYYMMDD)

2
0
0
3
0
4
1
5|13l Recipient’s date of birth (YYYYMMDD)
2
0
0
3
0
4
1
5|13l Recipient’s date of birth (YYYYMMDD)
2
0
0
3
0
4
1
5|13l Recipient’s date of birth (YYYYMMDD)
2
0
0
3
0
4
1
5|13l Recipient’s date of birth (YYYYMMDD)
2
0
0
3
0
4
1
5|13l Recipient’s date of birth (YYYYMMDD)
2
0
0
3
0
4
1
5|13l Recipient’s date of birth (YYYYMMDD)
2
0
0
3
0
4
1
5|13l Recipient’s date of birth (YYYYMMDD)
2
0
0
3
0
4
1
5|13l Recipient’s date of birth (YYYYMMDD)
2
0
0
3
0
4
1
5|13l Recipient’s date of birth (YYYYMMDD)
2
0
0
3
0
4
1
5|

XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
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.|7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
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.|7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
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.|7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
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.|7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
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.|7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
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.|7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
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.|7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
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.|7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
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.|7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
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.|7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
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.|7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
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.|7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
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.|7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
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.|7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
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.|7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
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.|7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
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.|7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
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.|7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
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.|7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
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.|7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
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.|7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
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.|7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
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.|7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
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.|7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
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.|7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
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.|7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
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.|7c Check if withholding occurred in subsequent year with respect to a
partnership interest .
.
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.
.
.|

XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|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|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|8 Tax withheld by other agents|8 Tax withheld by other agents|8 Tax withheld by other agents|8 Tax withheld by other agents|14a Primary Withholding Agent’s Name (if applicable)|14a Primary Withholding Agent’s Name (if applicable)|14a Primary Withholding Agent’s Name (if applicable)|14a Primary Withholding Agent’s Name (if applicable)|14a Primary Withholding Agent’s Name (if applicable)|14a Primary Withholding Agent’s Name (if applicable)|14a Primary Withholding Agent’s Name (if applicable)|14a Primary Withholding Agent’s Name (if applicable)|14a Primary Withholding Agent’s Name (if applicable)|14a Primary Withholding Agent’s Name (if applicable)|14a Primary Withholding Agent’s Name (if applicable)|14a Primary Withholding Agent’s Name (if applicable)|

XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( )|9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( )|9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( )|9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( )|9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( )|9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( )|9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( )|9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( )|9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( )|9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( )|9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( )|9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( )|9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( )|9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( )|9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( )|9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( )|9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( )|9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)

( )|9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( )|9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( )|9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( )|9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( )|9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( )|9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( )|9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( )|9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( )|9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( )|9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( )|

XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|

XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|10 Total withholding credit (combine boxes 7a, 8, and 9)|**15a **Intermediary or flow-through entity’s EIN, if any|**15a **Intermediary or flow-through entity’s EIN, if any|**15a **Intermediary or flow-through entity’s EIN, if any|**15a **Intermediary or flow-through entity’s EIN, if any|**15a **Intermediary or flow-through entity’s EIN, if any|15b Ch. 3 status code|15b Ch. 3 status code|15b Ch. 3 status code|15b Ch. 3 status code|15b Ch. 3 status code|15c Ch. 4 status|15c Ch. 4 status|

XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|

XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|11 Tax paid by withholding agent (amounts not withheld) (see instructions)|**15d **Intermediary or flow-through entity’s name|**15d **Intermediary or flow-through entity’s name|**15d **Intermediary or flow-through entity’s name|**15d **Intermediary or flow-through entity’s name|**15d **Intermediary or flow-through entity’s name|**15d **Intermediary or flow-through entity’s name|**15d **Intermediary or flow-through entity’s name|**15d **Intermediary or flow-through entity’s name|**15d **Intermediary or flow-through entity’s name|**15d **Intermediary or flow-through entity’s name|**15d **Intermediary or flow-through entity’s name|**15d **Intermediary or flow-through entity’s name|

XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|12aWithholding agent’s EIN
XX-XXXXXXX|12aWithholding agent’s EIN
XX-XXXXXXX|12aWithholding agent’s EIN
XX-XXXXXXX|12aWithholding agent’s EIN
XX-XXXXXXX|12aWithholding agent’s EIN
XX-XXXXXXX|12aWithholding agent’s EIN
XX-XXXXXXX|12aWithholding agent’s EIN
XX-XXXXXXX|12b Ch. 3 status code
02|12b Ch. 3 status code
02|12b Ch. 3 status code
02|12b Ch. 3 status code
02|12b Ch. 3 status code
02|12b Ch. 3 status code
02|12b Ch. 3 status code
02|12b Ch. 3 status code
02|**12c **Ch. 4 status code|**15e **Intermediary or flow-through entity’s GIIN|**15e **Intermediary or flow-through entity’s GIIN|**15e **Intermediary or flow-through entity’s GIIN|**15e **Intermediary or flow-through entity’s GIIN|**15e **Intermediary or flow-through entity’s GIIN|**15e **Intermediary or flow-through entity’s GIIN|**15e **Intermediary or flow-through entity’s GIIN|**15e **Intermediary or flow-through entity’s GIIN|**15e **Intermediary or flow-through entity’s GIIN|**15e **Intermediary or flow-through entity’s GIIN|**15e **Intermediary or flow-through entity’s GIIN|**15e **Intermediary or flow-through entity’s GIIN|

XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|12dWithholding agent’s name

|12dWithholding agent’s name

|12dWithholding agent’s name

|12dWithholding agent’s name

|12dWithholding agent’s name

|12dWithholding agent’s name

|12dWithholding agent’s name

|12dWithholding agent’s name

|12dWithholding agent’s name

|12dWithholding agent’s name

|12dWithholding agent’s name

|12dWithholding agent’s name

|12dWithholding agent’s name

|12dWithholding agent’s name

|12dWithholding agent’s name

|12dWithholding agent’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|15gForeign tax identification number, if any|

XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|12eWithholding agent’s Global Intermediary Identification Number (GIIN)|12eWithholding agent’s Global Intermediary Identification Number (GIIN)|12eWithholding agent’s Global Intermediary Identification Number (GIIN)|12eWithholding agent’s Global Intermediary Identification Number (GIIN)|12eWithholding agent’s Global Intermediary Identification Number (GIIN)|12eWithholding agent’s Global Intermediary Identification Number (GIIN)|12eWithholding agent’s Global Intermediary Identification Number (GIIN)|12eWithholding agent’s Global Intermediary Identification Number (GIIN)|12eWithholding agent’s Global Intermediary Identification Number (GIIN)|12eWithholding agent’s Global Intermediary Identification Number (GIIN)|12eWithholding agent’s Global Intermediary Identification Number (GIIN)|12eWithholding agent’s Global Intermediary Identification Number (GIIN)|12eWithholding agent’s Global Intermediary Identification Number (GIIN)|12eWithholding agent’s Global Intermediary Identification Number (GIIN)|12eWithholding agent’s Global Intermediary Identification Number (GIIN)|12eWithholding agent’s Global Intermediary Identification Number (GIIN)|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)|15hAddress (number and street)|

XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|12fCountry code|12fCountry code|12gForeign tax identification number, if any|12gForeign tax identification number, if any|12gForeign tax identification number, if any|12gForeign tax identification number, if any|12gForeign tax identification number, if any|12gForeign tax identification number, if any|12gForeign tax identification number, if any|12gForeign tax identification number, if any|12gForeign tax identification number, if any|12gForeign tax identification number, if any|12gForeign tax identification number, if any|12gForeign tax identification number, if any|12gForeign tax identification number, if any|12gForeign 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|15iCity or town, state or province, country, ZIP or foreign postal code|

XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|12hAddress (number and street)
221 WHITNEY AVENUE|12hAddress (number and street)
221 WHITNEY AVENUE|12hAddress (number and street)
221 WHITNEY AVENUE|12hAddress (number and street)
221 WHITNEY AVENUE|12hAddress (number and street)
221 WHITNEY AVENUE|12hAddress (number and street)
221 WHITNEY AVENUE|12hAddress (number and street)
221 WHITNEY AVENUE|12hAddress (number and street)
221 WHITNEY AVENUE|12hAddress (number and street)
221 WHITNEY AVENUE|12hAddress (number and street)
221 WHITNEY AVENUE|12hAddress (number and street)
221 WHITNEY AVENUE|12hAddress (number and street)
221 WHITNEY AVENUE|12hAddress (number and street)
221 WHITNEY AVENUE|12hAddress (number and street)
221 WHITNEY AVENUE|12hAddress (number and street)
221 WHITNEY AVENUE|12hAddress (number and street)
221 WHITNEY AVENUE|16aPayer’s name|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|

XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|12iCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN, YS XXXXX|12iCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN, YS XXXXX|12iCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN, YS XXXXX|12iCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN, YS XXXXX|12iCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN, YS XXXXX|12iCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN, YS XXXXX|12iCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN, YS XXXXX|12iCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN, YS XXXXX|12iCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN, YS XXXXX|12iCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN, YS XXXXX|12iCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN, YS XXXXX|12iCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN, YS XXXXX|12iCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN, YS XXXXX|12iCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN, YS XXXXX|12iCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN, YS XXXXX|12iCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN, YS XXXXX|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|16dCh. 3 status code|16eCh. 4 status c|16eCh. 4 status c|16eCh. 4 status c|

XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|13cAddress (number and street)

250 CHURCH STREET|13cAddress (number and street)

250 CHURCH STREET|13cAddress (number and street)

250 CHURCH STREET|13cAddress (number and street)

250 CHURCH STREET|13cAddress (number and street)

250 CHURCH STREET|13cAddress (number and street)

250 CHURCH STREET|13cAddress (number and street)

250 CHURCH STREET|13cAddress (number and street)

250 CHURCH STREET|13cAddress (number and street)

250 CHURCH STREET|13cAddress (number and street)

250 CHURCH STREET|13cAddress (number and street)

250 CHURCH STREET|13cAddress (number and street)

250 CHURCH STREET|13cAddress (number and street)

250 CHURCH STREET|13cAddress (number and street)

250 CHURCH STREET|13cAddress (number and street)

250 CHURCH STREET|13cAddress (number and street)

250 CHURCH STREET|||||||||||||

XX-XXXXXXX
02
221 WHITNEY AVENUE
YOUR TOWN, YS XXXXX
SIMONE DUPONT
250 CHURCH STREET
YOUR TOWN YS XXXXX
XXX-XX-XXXX
16
2
0
0
3
0
4
1
5|13dCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN YS XXXXX|13dCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN YS XXXXX|13dCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN YS XXXXX|13dCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN YS XXXXX|13dCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN YS XXXXX|13dCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN YS XXXXX|13dCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN YS XXXXX|13dCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN YS XXXXX|13dCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN YS XXXXX|13dCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN YS XXXXX|13dCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN YS XXXXX|13dCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN YS XXXXX|13dCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN YS XXXXX|13dCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN YS XXXXX|13dCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN YS XXXXX|13dCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN YS XXXXX|13dCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN YS XXXXX|13dCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN YS XXXXX|13dCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN YS XXXXX|13dCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN YS XXXXX|13dCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN YS XXXXX|13dCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN YS XXXXX|13dCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN YS XXXXX|13dCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN YS XXXXX|13dCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN YS XXXXX|13dCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN YS XXXXX|13dCity or town, state or province, country, ZIP or foreign postal code

YOUR TOWN YS XXXXX|13dCity or town, state or province, country, ZIP or foreign postal code
YOUR TOWN YS XXXXX|

Foreign Student Comprehensive Practice 80

Substantial Presence Test - Decision Tree

If you are temporarily present in the United States on an F, J, M, or Q visa, use this chart to determine if you are an exempt individual for the S ubstantial P resence T est (SPT).

Student F, J, or M Visa

Teacher – J or Q Visa

Trainee – J Visa

Do not count the following as days of presence in the United States for the substantial presence test: Days you are an exempt individual.

If additional days of presence due to COVID-19 travel restrictions cause the taxpayer to become a “resident” using the physical presence test rules, see possible exceptions allowed in Revenue Procedure 2020-20.

Foreign Student Comprehensive Practice 81

EXERCISES

Question 1: Begin by determining Simone’s residency status for federal tax purposes. What is Simone’s status?

a. Resident alien: U.S. residents who meet either the green card test or the substantial presence test

b. Nonresident alien: Individuals who are not citizens or residents of the United States

c. Dual status alien: Individuals who are both nonresidents and resident aliens for the tax year

Question 2: Must Simone file a tax return?

a. No, she does not have to file because she is a student

b. Yes, she must file because she has been in the U.S. less than 5 years

c. No, she does not have to file because she is a resident of a tax treaty country

d. Yes, she must file because she is claiming a tax treaty benefit

Question 3: What must Simone do with her stock transaction?

a. Does not need to be reported, she is in a nonresident alien status

b. Use the Form 8949 Sales and Other Dispositions of Capital Assets to report the sale.

c. Review the applicable Tax Treaty for the tax rate and report on the Schedule NEC, Tax on Income Not

Effectively Connected with a U.S. Trade or Business

d. If the Tax Treaty has a rate of zero, the item does not need to be reported on the tax return

Question 4: Simone can file a Form 1040-NR.

a. True

b. False

Foreign Student Comprehensive Practice 82

Tax Forms

You assist Simone in completing her Form 1040-NR

Foreign Student Comprehensive Practice 83

Foreign Student Comprehensive Practice 84

Question 5: Why did Simone file Form 8233 with her U.S. employer?

a. So her employer could legitimately not withhold federal income taxes until her treaty benefit amount

was exceeded

b. So her employer could withhold federal income taxes at a reduced rate

c. To document her presence in the United States for use in the substantial presence test at a later date

d. To exclude her scholarship from U.S. taxes

Foreign Student Comprehensive Practice 85

Foreign Student Comprehensive Practice 86

Question 6: Should Simone complete Form 8843?

a. No, she is exempt from the substantial presence test

b. Yes, it allows her to exclude her days of presence in the U.S. while on F-1 immigration status

c. No, she does not have a medical condition

d. Yes, it allows her employer to not withhold Social Security taxes

Foreign Student Comprehensive Practice 87

Foreign Student Comprehensive Practice 88

Question 7: True or False? Simone should use the Single filing status.

a. True

b. False

Income Sources

Question 8: What does tax treaty Code 16 on Simone’s Form 1042-S indicate about the source of her $14,500?

a. It is a scholarship or fellowship grant

b. It is taxable earned income

c. It is compensation for teaching or researching

d. It is compensation earned during study

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.

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

OMB No. 1545-0096

			0	1	2	3		4	5		6	7	8	9
1 Income code 16	2Gross income 14500	2Gross income 14500	3 Chapter indicator. Enter “3” or “4” 3	3 Chapter indicator. Enter “3” or “4” 3	3 Chapter indicator. Enter “3” or “4” 3	3 Chapter indicator. Enter “3” or “4” 3	3 Chapter indicator. Enter “3” or “4” 3	3 Chapter indicator. Enter “3” or “4” 3	3 Chapter indicator. Enter “3” or “4” 3	3 Chapter indicator. Enter “3” or “4” 3	3 Chapter indicator. Enter “3” or “4” 3	3 Chapter indicator. Enter “3” or “4” 3	3 Chapter indicator. Enter “3” or “4” 3	3 Chapter indicator. Enter “3” or “4” 3	3 Chapter indicator. Enter “3” or “4” 3	13eRecipient’s U.S. TIN, if any XXX-XX-XXXX	13eRecipient’s U.S. TIN, if any XXX-XX-XXXX	13eRecipient’s U.S. TIN, if any XXX-XX-XXXX	13eRecipient’s U.S. TIN, if any XXX-XX-XXXX	13fCh. 3 status code 16	13fCh. 3 status code 16	13fCh. 3 status code 16	13fCh. 3 status code 16	13fCh. 3 status code 16	13fCh. 3 status code 16	13fCh. 3 status code 16
1 Income code 16	2Gross income 14500	2Gross income 14500	3a Exemption code 04	3a Exemption code 04	3a Exemption code 04	3a Exemption code 04	3a Exemption code 04	3a Exemption code 04	3a Exemption code 04	3a Exemption code 04	3a Exemption code 04	3a Exemption code 04	4a Exemption code	4a Exemption code	4a Exemption code	4a Exemption code	4a Exemption code	4a Exemption code	4a Exemption 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 16	2Gross income 14500	2Gross income 14500	3b Tax rate . 0 00	3b Tax rate . 0 00	3b Tax rate . 0 00	3b Tax rate . 0 00	3b Tax rate . 0 00	3b Tax rate . 0 00	3b Tax rate . 0 00	3b Tax rate . 0 00	3b Tax rate . 0 00	3b Tax rate . 0 00	4b Tax rate .	4b Tax rate .	4b Tax 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
5Withholding allowance
6Net income 14500	6Net income 14500	6Net income 14500	6Net income 14500	6Net income 14500	6Net income 14500	6Net income 14500	6Net income 14500	6Net income 14500	6Net income 14500	6Net income 14500	6Net income 14500	6Net income 14500	6Net income 14500	6Net income 14500	6Net income 14500	6Net income 14500	6Net income 14500	6Net income 14500	6Net income 14500	6Net income 14500	6Net income 14500	6Net income 14500	6Net income 14500	6Net income 14500	6Net income 14500	6Net income 14500
7a Federal tax withheld	7a Federal tax withheld	7a Federal tax withheld	7a Federal tax withheld	7a Federal tax withheld	7a Federal tax withheld	7a Federal tax withheld	7a Federal tax withheld	7a Federal tax withheld	7a Federal tax withheld	7a Federal tax withheld	7a Federal tax withheld	7a Federal tax withheld	7a Federal tax withheld	7a Federal tax withheld	7a Federal 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
7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .
7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	13l Recipient’s date of birth (YYYYMMDD) 2 0 0 3 0 4 1 5	13l Recipient’s date of birth (YYYYMMDD) 2 0 0 3 0 4 1 5	13l Recipient’s date of birth (YYYYMMDD) 2 0 0 3 0 4 1 5	13l Recipient’s date of birth (YYYYMMDD) 2 0 0 3 0 4 1 5	13l Recipient’s date of birth (YYYYMMDD) 2 0 0 3 0 4 1 5	13l Recipient’s date of birth (YYYYMMDD) 2 0 0 3 0 4 1 5	13l Recipient’s date of birth (YYYYMMDD) 2 0 0 3 0 4 1 5	13l Recipient’s date of birth (YYYYMMDD) 2 0 0 3 0 4 1 5	13l Recipient’s date of birth (YYYYMMDD) 2 0 0 3 0 4 1 5	13l Recipient’s date of birth (YYYYMMDD) 2 0 0 3 0 4 1 5	13l Recipient’s date of birth (YYYYMMDD) 2 0 0 3 0 4 1 5
7c Check if withholding occurred in subsequent year with respect to a partnership interest . . . . . . . . . . . . . .
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	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	8 Tax withheld by other agents	8 Tax withheld by other agents	8 Tax withheld by other agents	8 Tax withheld by other agents	14a Primary Withholding Agent’s Name (if applicable)	14a Primary Withholding Agent’s Name (if applicable)	14a Primary Withholding Agent’s Name (if applicable)	14a Primary Withholding Agent’s Name (if applicable)	14a Primary Withholding Agent’s Name (if applicable)	14a Primary Withholding Agent’s Name (if applicable)	14a Primary Withholding Agent’s Name (if applicable)	14a Primary Withholding Agent’s Name (if applicable)	14a Primary Withholding Agent’s Name (if applicable)	14a Primary Withholding Agent’s Name (if applicable)	14a Primary Withholding Agent’s Name (if applicable)
9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )
9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	14bPrimary Withholding Agent’s EIN	14bPrimary Withholding Agent’s EIN	14bPrimary Withholding Agent’s EIN	14bPrimary Withholding Agent’s EIN	15 Check if pro-rata basis reporting	15 Check if pro-rata basis reporting	15 Check if pro-rata basis reporting	15 Check if pro-rata basis reporting	15 Check if pro-rata basis reporting	15 Check if pro-rata basis reporting	15 Check if pro-rata basis reporting
10 Total withholding credit (combine boxes 7a, 8, and 9)
10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	15a Intermediary or flow-through entity’s EIN, if any	15a Intermediary or flow-through entity’s EIN, if any	15a Intermediary or flow-through entity’s EIN, if any	15a Intermediary or flow-through entity’s EIN, if any	15a Intermediary or flow-through entity’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
11 Tax paid by withholding agent (amounts not withheld) (see instructions)
11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	15d Intermediary or flow-through entity’s name	15d Intermediary or flow-through entity’s name	15d Intermediary or flow-through entity’s name	15d Intermediary or flow-through entity’s name	15d Intermediary or flow-through entity’s name	15d Intermediary or flow-through entity’s name	15d Intermediary or flow-through entity’s name	15d Intermediary or flow-through entity’s name	15d Intermediary or flow-through entity’s name	15d Intermediary or flow-through entity’s name	15d Intermediary or flow-through entity’s name
12aWithholding agent’s EIN XX-XXXXXXX	12aWithholding agent’s EIN XX-XXXXXXX	12aWithholding agent’s EIN XX-XXXXXXX	12aWithholding agent’s EIN XX-XXXXXXX	12aWithholding agent’s EIN XX-XXXXXXX	12aWithholding agent’s EIN XX-XXXXXXX	12aWithholding agent’s EIN XX-XXXXXXX	12b Ch. 3 status code 02	12b Ch. 3 status code 02	12b Ch. 3 status code 02	12b Ch. 3 status code 02	12b Ch. 3 status code 02	12b Ch. 3 status code 02	12b Ch. 3 status code 02	12b Ch. 3 status code 02	12c Ch. 4 status code	12c Ch. 4 status code	12c Ch. 4 status code	12c Ch. 4 status code	12c Ch. 4 status code	12c Ch. 4 status code	12c Ch. 4 status code	12c Ch. 4 status code	12c Ch. 4 status code	12c Ch. 4 status code	12c Ch. 4 status code	12c Ch. 4 status code
12aWithholding agent’s EIN XX-XXXXXXX	12aWithholding agent’s EIN XX-XXXXXXX	12aWithholding agent’s EIN XX-XXXXXXX	12aWithholding agent’s EIN XX-XXXXXXX	12aWithholding agent’s EIN XX-XXXXXXX	12aWithholding agent’s EIN XX-XXXXXXX	12aWithholding agent’s EIN XX-XXXXXXX	12b Ch. 3 status code 02	12b Ch. 3 status code 02	12b Ch. 3 status code 02	12b Ch. 3 status code 02	12b Ch. 3 status code 02	12b Ch. 3 status code 02	12b Ch. 3 status code 02	12b Ch. 3 status code 02	12c Ch. 4 status code	15e Intermediary or flow-through entity’s GIIN	15e Intermediary or flow-through entity’s GIIN	15e Intermediary or flow-through entity’s GIIN	15e Intermediary or flow-through entity’s GIIN	15e Intermediary or flow-through entity’s GIIN	15e Intermediary or flow-through entity’s GIIN	15e Intermediary or flow-through entity’s GIIN	15e Intermediary or flow-through entity’s GIIN	15e Intermediary or flow-through entity’s GIIN	15e Intermediary or flow-through entity’s GIIN	15e Intermediary or flow-through entity’s GIIN
12dWithholding agent’s name	12dWithholding agent’s name	12dWithholding agent’s name	12dWithholding agent’s name	12dWithholding agent’s name	12dWithholding agent’s name	12dWithholding agent’s name	12dWithholding agent’s name	12dWithholding agent’s name	12dWithholding agent’s name	12dWithholding agent’s name	12dWithholding agent’s name	12dWithholding agent’s name	12dWithholding agent’s name	12dWithholding agent’s name	12dWithholding agent’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 Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	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 tax identification number, if any	12gForeign tax identification number, if any	12gForeign tax identification number, if any	12gForeign tax identification number, if any	12gForeign tax identification number, if any	12gForeign tax identification number, if any	12gForeign tax identification number, if any	12gForeign tax identification number, if any	12gForeign tax identification number, if any	12gForeign tax identification number, if any	12gForeign tax identification number, if any	12gForeign tax identification number, if any	12gForeign tax identification number, if any	12gForeign 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) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	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, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	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’s name SIMONE DUPONT	13aRecipient’s name SIMONE DUPONT	13aRecipient’s name SIMONE DUPONT	13aRecipient’s name SIMONE DUPONT	13aRecipient’s name SIMONE DUPONT	13aRecipient’s name SIMONE DUPONT	13aRecipient’s name SIMONE DUPONT	13aRecipient’s name SIMONE DUPONT	13aRecipient’s name SIMONE DUPONT	13aRecipient’s name SIMONE DUPONT	13b Recipient’s country code	13b Recipient’s country code	13b Recipient’s country code	13b Recipient’s country code	13b Recipient’s country code	13b Recipient’s country code	17aState income tax withheld	17aState income tax withheld	17aState income tax withheld	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) 250 CHURCH STREET
13dCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX

Foreign Student Comprehensive Practice 89

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.

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

OMB No. 1545-0096

			0	1	2	3		4	5		6	7	8	9
1 Income code 20	2Gross income 5000	2Gross income 5000	3 Chapter indicator. Enter “3” or “4” 3	3 Chapter indicator. Enter “3” or “4” 3	3 Chapter indicator. Enter “3” or “4” 3	3 Chapter indicator. Enter “3” or “4” 3	3 Chapter indicator. Enter “3” or “4” 3	3 Chapter indicator. Enter “3” or “4” 3	3 Chapter indicator. Enter “3” or “4” 3	3 Chapter indicator. Enter “3” or “4” 3	3 Chapter indicator. Enter “3” or “4” 3	3 Chapter indicator. Enter “3” or “4” 3	3 Chapter indicator. Enter “3” or “4” 3	3 Chapter indicator. Enter “3” or “4” 3	3 Chapter indicator. Enter “3” or “4” 3	13eRecipient’s U.S. TIN, if any XXX-XX-XXXX	13eRecipient’s U.S. TIN, if any XXX-XX-XXXX	13eRecipient’s U.S. TIN, if any XXX-XX-XXXX	13eRecipient’s U.S. TIN, if any XXX-XX-XXXX	13fCh. 3 status code 16	13fCh. 3 status code 16	13fCh. 3 status code 16	13fCh. 3 status code 16	13fCh. 3 status code 16	13fCh. 3 status code 16	13fCh. 3 status code 16
1 Income code 20	2Gross income 5000	2Gross income 5000	3a Exemption code 04	3a Exemption code 04	3a Exemption code 04	3a Exemption code 04	3a Exemption code 04	3a Exemption code 04	3a Exemption code 04	3a Exemption code 04	3a Exemption code 04	3a Exemption code 04	4a Exemption code	4a Exemption code	4a Exemption code	4a Exemption code	4a Exemption code	4a Exemption code	4a Exemption 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 20	2Gross income 5000	2Gross income 5000	3b Tax rate . 0 00	3b Tax rate . 0 00	3b Tax rate . 0 00	3b Tax rate . 0 00	3b Tax rate . 0 00	3b Tax rate . 0 00	3b Tax rate . 0 00	3b Tax rate . 0 00	3b Tax rate . 0 00	3b Tax rate . 0 00	4b Tax rate .	4b Tax rate .	4b Tax 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
5Withholding allowance
6Net income 5000	6Net income 5000	6Net income 5000	6Net income 5000	6Net income 5000	6Net income 5000	6Net income 5000	6Net income 5000	6Net income 5000	6Net income 5000	6Net income 5000	6Net income 5000	6Net income 5000	6Net income 5000	6Net income 5000	6Net income 5000	6Net income 5000	6Net income 5000	6Net income 5000	6Net income 5000	6Net income 5000	6Net income 5000	6Net income 5000	6Net income 5000	6Net income 5000	6Net income 5000	6Net income 5000
7a Federal tax withheld	7a Federal tax withheld	7a Federal tax withheld	7a Federal tax withheld	7a Federal tax withheld	7a Federal tax withheld	7a Federal tax withheld	7a Federal tax withheld	7a Federal tax withheld	7a Federal tax withheld	7a Federal tax withheld	7a Federal tax withheld	7a Federal tax withheld	7a Federal tax withheld	7a Federal tax withheld	7a Federal 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
7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .
7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	7b Check if federal tax withheld was not deposited with the IRS because escrow procedures were applied (see instructions) . . . . . .	13l Recipient’s date of birth (YYYYMMDD) 2 0 0 3 0 4 1 5	13l Recipient’s date of birth (YYYYMMDD) 2 0 0 3 0 4 1 5	13l Recipient’s date of birth (YYYYMMDD) 2 0 0 3 0 4 1 5	13l Recipient’s date of birth (YYYYMMDD) 2 0 0 3 0 4 1 5	13l Recipient’s date of birth (YYYYMMDD) 2 0 0 3 0 4 1 5	13l Recipient’s date of birth (YYYYMMDD) 2 0 0 3 0 4 1 5	13l Recipient’s date of birth (YYYYMMDD) 2 0 0 3 0 4 1 5	13l Recipient’s date of birth (YYYYMMDD) 2 0 0 3 0 4 1 5	13l Recipient’s date of birth (YYYYMMDD) 2 0 0 3 0 4 1 5	13l Recipient’s date of birth (YYYYMMDD) 2 0 0 3 0 4 1 5	13l Recipient’s date of birth (YYYYMMDD) 2 0 0 3 0 4 1 5
7c Check if withholding occurred in subsequent year with respect to a partnership interest . . . . . . . . . . . . . .
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	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	8 Tax withheld by other agents	8 Tax withheld by other agents	8 Tax withheld by other agents	8 Tax withheld by other agents	14a Primary Withholding Agent’s Name (if applicable)	14a Primary Withholding Agent’s Name (if applicable)	14a Primary Withholding Agent’s Name (if applicable)	14a Primary Withholding Agent’s Name (if applicable)	14a Primary Withholding Agent’s Name (if applicable)	14a Primary Withholding Agent’s Name (if applicable)	14a Primary Withholding Agent’s Name (if applicable)	14a Primary Withholding Agent’s Name (if applicable)	14a Primary Withholding Agent’s Name (if applicable)	14a Primary Withholding Agent’s Name (if applicable)	14a Primary Withholding Agent’s Name (if applicable)
9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )
9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions) ( )	14bPrimary Withholding Agent’s EIN	14bPrimary Withholding Agent’s EIN	14bPrimary Withholding Agent’s EIN	14bPrimary Withholding Agent’s EIN	15 Check if pro-rata basis reporting	15 Check if pro-rata basis reporting	15 Check if pro-rata basis reporting	15 Check if pro-rata basis reporting	15 Check if pro-rata basis reporting	15 Check if pro-rata basis reporting	15 Check if pro-rata basis reporting
10 Total withholding credit (combine boxes 7a, 8, and 9)
10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	10 Total withholding credit (combine boxes 7a, 8, and 9)	15a Intermediary or flow-through entity’s EIN, if any	15a Intermediary or flow-through entity’s EIN, if any	15a Intermediary or flow-through entity’s EIN, if any	15a Intermediary or flow-through entity’s EIN, if any	15a Intermediary or flow-through entity’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
11 Tax paid by withholding agent (amounts not withheld) (see instructions)
11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	11 Tax paid by withholding agent (amounts not withheld) (see instructions)	15d Intermediary or flow-through entity’s name	15d Intermediary or flow-through entity’s name	15d Intermediary or flow-through entity’s name	15d Intermediary or flow-through entity’s name	15d Intermediary or flow-through entity’s name	15d Intermediary or flow-through entity’s name	15d Intermediary or flow-through entity’s name	15d Intermediary or flow-through entity’s name	15d Intermediary or flow-through entity’s name	15d Intermediary or flow-through entity’s name	15d Intermediary or flow-through entity’s name
12aWithholding agent’s EIN XX-XXXXXXX	12aWithholding agent’s EIN XX-XXXXXXX	12aWithholding agent’s EIN XX-XXXXXXX	12aWithholding agent’s EIN XX-XXXXXXX	12aWithholding agent’s EIN XX-XXXXXXX	12aWithholding agent’s EIN XX-XXXXXXX	12aWithholding agent’s EIN XX-XXXXXXX	12b Ch. 3 status code 02	12b Ch. 3 status code 02	12b Ch. 3 status code 02	12b Ch. 3 status code 02	12b Ch. 3 status code 02	12b Ch. 3 status code 02	12b Ch. 3 status code 02	12b Ch. 3 status code 02	12c Ch. 4 status code	12c Ch. 4 status code	12c Ch. 4 status code	12c Ch. 4 status code	12c Ch. 4 status code	12c Ch. 4 status code	12c Ch. 4 status code	12c Ch. 4 status code	12c Ch. 4 status code	12c Ch. 4 status code	12c Ch. 4 status code	12c Ch. 4 status code
12aWithholding agent’s EIN XX-XXXXXXX	12aWithholding agent’s EIN XX-XXXXXXX	12aWithholding agent’s EIN XX-XXXXXXX	12aWithholding agent’s EIN XX-XXXXXXX	12aWithholding agent’s EIN XX-XXXXXXX	12aWithholding agent’s EIN XX-XXXXXXX	12aWithholding agent’s EIN XX-XXXXXXX	12b Ch. 3 status code 02	12b Ch. 3 status code 02	12b Ch. 3 status code 02	12b Ch. 3 status code 02	12b Ch. 3 status code 02	12b Ch. 3 status code 02	12b Ch. 3 status code 02	12b Ch. 3 status code 02	12c Ch. 4 status code	15e Intermediary or flow-through entity’s GIIN	15e Intermediary or flow-through entity’s GIIN	15e Intermediary or flow-through entity’s GIIN	15e Intermediary or flow-through entity’s GIIN	15e Intermediary or flow-through entity’s GIIN	15e Intermediary or flow-through entity’s GIIN	15e Intermediary or flow-through entity’s GIIN	15e Intermediary or flow-through entity’s GIIN	15e Intermediary or flow-through entity’s GIIN	15e Intermediary or flow-through entity’s GIIN	15e Intermediary or flow-through entity’s GIIN
12dWithholding agent’s name	12dWithholding agent’s name	12dWithholding agent’s name	12dWithholding agent’s name	12dWithholding agent’s name	12dWithholding agent’s name	12dWithholding agent’s name	12dWithholding agent’s name	12dWithholding agent’s name	12dWithholding agent’s name	12dWithholding agent’s name	12dWithholding agent’s name	12dWithholding agent’s name	12dWithholding agent’s name	12dWithholding agent’s name	12dWithholding agent’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 Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	12eWithholding agent’s Global Intermediary Identification Number (GIIN)	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 tax identification number, if any	12gForeign tax identification number, if any	12gForeign tax identification number, if any	12gForeign tax identification number, if any	12gForeign tax identification number, if any	12gForeign tax identification number, if any	12gForeign tax identification number, if any	12gForeign tax identification number, if any	12gForeign tax identification number, if any	12gForeign tax identification number, if any	12gForeign tax identification number, if any	12gForeign tax identification number, if any	12gForeign tax identification number, if any	12gForeign 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) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	12hAddress (number and street) 221 WHITNEY AVENUE	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, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	12iCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX	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’s name SIMONE DUPONT	13aRecipient’s name SIMONE DUPONT	13aRecipient’s name SIMONE DUPONT	13aRecipient’s name SIMONE DUPONT	13aRecipient’s name SIMONE DUPONT	13aRecipient’s name SIMONE DUPONT	13aRecipient’s name SIMONE DUPONT	13aRecipient’s name SIMONE DUPONT	13aRecipient’s name SIMONE DUPONT	13aRecipient’s name SIMONE DUPONT	13b Recipient’s country code	13b Recipient’s country code	13b Recipient’s country code	13b Recipient’s country code	13b Recipient’s country code	13b Recipient’s country code	17aState income tax withheld	17aState income tax withheld	17aState income tax withheld	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) 250 CHURCH STREET
13dCity or town, state or province, country, ZIP or foreign postal code YOUR TOWN, YS XXXXX

Question 9: Based on her country’s treaty benefits, how much of Simone’s $12,225 studying income is exempt from U.S. taxes?

a. $0

b. $5,000

c. $7,225

d. $12,225

Foreign Student Comprehensive Practice 90

Countries With Treaty Benefits for Studying and Training (Income Code 20)

The following is a quick-reference summary of treaty benefits. For more information about the application of these treaty benefits, see Publication 901.

2-year limit applies to business or technical apprentices.

L Treaty contains provisions that retroactively eliminates benefits if the allowable period in the U.S. or income amounts are exceeded as defined in the treaty.

Tax Treaty provisions allowed federally may not be honored by some states. Contact your state to see if treaty provisions are honored on the state return.

Foreign Student Comprehensive Practice 91

Question 10: True or False? Simone must report all of her U.S. income sources on her return.

a. True

b. False

Completing the Return

You are now ready to help Simone prepare her tax return. Next, review her documents and complete Form 1040-NR, pages 1 and 2.