Form 1042-T Annual Summary and Transmittal of Forms 1042-S
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

Amended Amended pro rata Original Original pro rata (: Amended) Unchecked (: Original) Unchecked (checkbox) Unchecked (checkbox) Unchecked (text) (text) (text) (text) (text) 1042 S instructions) also check the pro rata box As a result there 1042 T 1a Type of paper Forms 1042 S attached (check only one box): Original Amended 2a Total gross income on all paper Forms 1042 S (box 2) attached $ Also check here if pro rata (see instructions) Amended box If you are filing pro rata Forms 1042 S (see Form and file this form will vary depending on individual circumstances Annual Summary and Transmittal of are four possible types of Form 1042 S that may be transmitted: b Number of paper Forms 1042 S attached b Total federal tax withheld on all paper Forms 1042 S (box 9) attached $ CAUTION Caution: If you have already filed a Form 1042 and an attached Form 1042 S causes the gross income or tax withheld Center; P O Box 409101; Ogden UT 84409; by March 15 2013 City or town province or state and country (including postal code) Date Daytime phone number Department of the Treasury DO NOT STAPLE each type of Form 1042 S (see the instructions for line 1a) Each type would be transmitted with a separate Form 1042 T For EIN of the withholding agent or intermediary on this form must be Employer identification number even though changes reflect differences in gross income and tax example you would transmit only original Forms 1042 S with one filing your Form 1042 You may submit amended Forms 1042 S Final return If you will not be required to file Forms 1042 S in the for information on filing electronically For more information and the Privacy Act and Paperwork Reduction Act Notice see Form 1042 S Cat No 28848W Form 1042 T (2012) Foreign Person s U S Source Income Subject to Withholding to the Form 1042 S caused the gross income or tax withheld information Form 1042 T Form 1042 T and only amended Forms 1042 S with another Form Forms 1042 S Forms 1042 S (box 2) being transmitted with this Form 1042 T Forms 1042 S electronically do not use Form 1042 T future (on paper or electronically) enter an X in the FINAL return Identifying information at top of form The name address and If this is your FINAL return enter an X here (see instructions) If you are an intermediary (see Form 1042 instructions) check if you are a: QI/Withholding foreign partnership or trust If you file 250 or more Forms 1042 S you are required to If you have already filed a Form 1042 for 2012 and an attached If you have not yet filed a Form 1042 for 2012 you may send in information shown on your previously filed Form 1042 to change you must file an amended Form 1042 See the Instructions instructions below instructions for Form 1042 for definitions of withholding agent and intermediary Internal Revenue Service Internal Revenue Service Use a separate Form 1042 T to transmit Line 1a You must file a separate Form 1042 T for each type of Line 2a Enter the total of the gross income amounts shown on the Line 2b Enter the total of the federal tax withheld amounts shown more than one Form 1042 T to submit paper Forms 1042 S prior to Name of withholding agent NQI/Flow through entity Number street and room or suite no OMB No 1545 0096 on the Forms 1042 S (box 9) being transmitted with this Form paper Form 1042 S you are transmitting Check only the Original or paper Forms 1042 S being transmitted) with the Ogden Service Paperwork Reduction Act Notice The time needed to complete Person's U S Source Income Subject to Withholding Electronically Please return this entire page to the Internal Revenue Service previously reported on line 62a or 62b of your Form 1042 to change Purpose of form Use this form to transmit paper Forms 1042 S See Pub 1187 Specifications for Filing Form 1042 S Foreign Send the forms in a flat mailing (not folded) Sign belief they are true correct and complete submit them electronically You also can use this method The estimated average time is 12 minutes the same as those you enter on Forms 1042 and 1042 S See the to submit less than 250 Forms 1042 S If you submit U S Source Income of Foreign Persons Under penalties of perjury I declare that I have examined this return and accompanying documents and to the best of my knowledge and Use of this form to transmit paper Forms 1042 S does not affect Where and when to file File Form 1042 T (and Copy A of the withheld information of Forms 1042 S previously submitted with a you must file an amended Form 1042 your obligation to file Form 1042 Annual Withholding Tax Return for Your signature Title