Foreign Person’s U.S. Source Income Subject to Withholding                                                                                OMB No. 1545-0096
Form 1042-S                   Go to www.irs.gov/Form1042S for instructions and the latest information.                                   2024                                              for  
Department of the Treasury                                                                                                                                            Copy A 
Internal Revenue Service                                        UNIQUE FORM IDENTIFIER                         AMENDED             AMENDMENT NO.                     Internal Revenue Service
1 Income  2  Gross income   3   Chapter indicator.  Enter “3” or “4”                                      13e  Recipient’s U.S. TIN, if any              13f  Ch. 3 status code
  code
                            3a Exemption code             4a Exemption code                                                                              13g Ch. 4 status code
                            3b Tax rate            .      4b Tax rate      .                              13h  Recipient’s GIIN          13i  Recipient ’sforeign tax identification13j  LOB code 
                                                                                                                                              number, if any
5  Withholding allowance
6  Net income
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 
    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
10  Total withholding credit (combine boxes 7a, 8, and 9)                                                                                                15  Check if pro-rata basis reporting 
                                                                                                          15a  Intermediary or flow-through entity’s EIN, if any 15b Ch. 3 status code 15c Ch. 4 status code
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 code12c  Ch. 4 status code
                                                                                                          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

12i  City or town, state or province, country, ZIP or foreign postal code                                 16c  Payer’s GIIN                              16d Ch. 3 status code16e Ch. 4 status code

13a  Recipient’s name                          13b  Recipient’s country code                              17a  State income tax withheld      17b  Payer’s state tax no.  17c  Name of state

13c  Address (number and street)

13d  City or town, state or province, country, ZIP or foreign postal code

For Privacy Act and Paperwork Reduction Act Notice, see instructions.                                                       Cat. No. 11386R                               Form 1042-S (2024)

                            Foreign Person’s U.S. Source Income Subject to Withholding                                                                               OMB No. 1545-0096
Form 1042-S                     Go to www.irs.gov/Form1042S for instructions and the latest information.                            2024
Department of the Treasury                                                                                                                                           Copy B   
Internal Revenue Service                                        UNIQUE FORM IDENTIFIER                         AMENDED             AMENDMENT NO.                     for Recipient
1 Income  2  Gross income   3   Chapter indicator.  Enter “3” or “4”                                      13e  Recipient’s U.S. TIN, if any              13f  Ch. 3 status code
  code
                            3a Exemption code             4a Exemption code                                                                              13g Ch. 4 status code
                            3b Tax rate            .      4b Tax rate      .                              13h  Recipient’s GIIN     13i  Recipient ’sforeign tax identification13j  LOB code 
                                                                                                                                            number, if any
5  Withholding allowance
6  Net income
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 
    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
10  Total withholding credit (combine boxes 7a, 8, and 9)                                                                                                15  Check if pro-rata basis reporting 
                                                                                                          15a  Intermediary or flow-through entity’s EIN, if any 15b Ch. 3 status code 15c Ch. 4 status code
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 code12c  Ch. 4 status code
                                                                                                          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

12i  City or town, state or province, country, ZIP or foreign postal code                                 16c  Payer’s GIIN                              16d Ch. 3 status code16e Ch. 4 status code

13a  Recipient’s name                          13b  Recipient’s country code                              17a  State income tax withheld    17b  Payer’s state tax no.    17c  Name of state

13c  Address (number and street)

13d  City or town, state or province, country, ZIP or foreign postal code

(keep for your records)                                                                                                                                                   Form 1042-S (2024)

U.S. Income Tax Filing Requirements                                                Por regla general, todo extranjero no residente, todo organismo 
                                                                                fideicomisario extranjero no residente y toda sociedad anónima 
Generally, every nonresident alien individual, nonresident alien                extranjera que reciba ingresos en los Estados Unidos, incluyendo 
fiduciary, and foreign corporation with U.S. income, including income           ingresos relacionados con la conducción de un negocio o comercio 
that is effectively connected with the conduct of a trade or business in        dentro de los Estados Unidos, deberá presentar una declaración 
the United States, must file a U.S. income tax return. However, no              estadounidense de impuestos sobre el ingreso. Sin embargo, no se 
return is required to be filed by a nonresident alien individual,               requiere declaración alguna a un individuo extranjero, una sociedad 
nonresident alien fiduciary, or foreign corporation if such person was          anónima extranjera u organismo fideicomisario extranjero no 
not engaged in a trade or business in the United States at any time             residente, si tal persona no ha efectuado comercio o negocio en los 
during the tax year and if the tax liability of such person was fully           Estados Unidos durante el año fiscal y si la responsabilidad con los 
satisfied by the withholding of U.S. tax at the source. Corporations file       impuestos de tal persona ha sido satisfecha plenamente mediante 
Form 1120-F; all others file Form 1040-NR. You may get the return               retención del impuesto de los Estados Unidos en la fuente. Las 
forms and instructions at IRS.gov, at any U.S. Embassy or consulate,            sociedades anónimas envían el Formulario 1120-F; todos los demás 
or by writing to: Internal Revenue Service, 1201 N. Mitsubishi                  contribuyentes envían el Formulario 1040-NR. Se podrá obtener 
Motorway, Bloomington, IL 61705-6613.                                           formularios e instrucciones en IRS.gov y en cualquier Embajada o 
  En règle générale, tout étranger non-résident, tout organisme                 Consulado de los Estados Unidos o escribiendo directamente a: 
fidéicommissaire étranger non-résident et toute société étrangère               Internal Revenue Service, 1201 N. Mitsubishi Motorway, Bloomington, 
percevant un revenu aux Etats-Unis, y compris tout revenu dérivé, en            IL 61705-6613.
fait, du fonctionnement d’un commerce ou d’une affaire aux Etats-                  Im allgemeinen muss jede ausländische Einzelperson, jeder 
Unis, doit produire une déclaration d’impôt sur le revenu auprès des            ausländische Bevollmächtigte und jede ausländische Gesellschaft mit 
services fiscaux des Etats-Unis. Cependant aucune déclaration                   Einkommen in den Vereinigten Staaten, einschliesslich des 
d’impôt sur le revenu n’est exigée d’un étranger non-résident, d’un             Einkommens, welches direkt mit der Ausübung von Handel oder 
organisme fidéicommissaire étranger non-résident, ou d’une société              Gewerbe innerhalb der Staaten verbunden ist, eine 
étrangère s’ils n’ont pris part à aucun commerce ou affaire aux Etats-          Einkommensteuererklärung der Vereinigten Staaten abgeben. Eine 
Unis à aucun moment pendant l’année fiscale et si les impôts dont ils           Erklärung, muss jedoch nicht von Ausländern, ausländischen 
sont redevables, ont été entièrement acquittés par une retenue à la             Bevollmächtigten oder ausländischen Gesellschaften in den 
source sur leur salaire. Les sociétés doivent faire leur déclaration            Vereinigten Staaten eingereicht werden, falls eine solche Person 
d’impôt en remplissant le formulaire 1120-F; tous les autres                    während des Steuerjahres kein Gewerbe oder Handel in den 
redevables doivent remplir le formulaire 1040-NR. On peut se procurer           Vereinigten Staaten ausgeübt hat und die Steuerschuld durch 
les formulaires de déclarations d’impôts et les instructions y afférentes       Einbehaltung der Steuern der Vereinigten Staaten durch die 
à IRS.gov et dans toutes les ambassades et tous les consulats des               Einkommensquelle abgegolten ist. Gesellschaften reichen den 
Etats-Unis. L’on peut également s’adresser pour tout renseignement              Vordruck 1120-F ein; alle anderen reichen das Formblatt 1040-NR ein. 
à: Internal Revenue Service, 1201 N. Mitsubishi Motorway,                       Einkommensteuererklärungen und Instruktionen können unter IRS.gov 
Bloomington, IL 61705-6613.                                                     und bei den Botschaften und Konsulaten der Vereinigten Staaten 
                                                                                eingeholt werden. Um weitere Informationen wende man sich bitte an: 
                                                                                Internal Revenue Service, 1201 N. Mitsubishi Motorway,  
                                                                                Bloomington, IL 61705-6613.

Explanation of Codes                                                                  34          Substitute payment—dividends
Box 1. Income Code.                                                                   40          Other dividend equivalents under IRC section 871(m) 
  Code                           Types of Income                                      52          Dividends paid on certain actively traded or publicly offered 
     01       Interest paid by U.S. obligors—general                                              securities1
     02       Interest paid on real property mortgages                                Dividend 53 Substitute payments-dividends from certain actively traded or 
     03       Interest paid to controlling foreign corporations                                   publicly offered securities1
     04       Interest paid by foreign corporations                                   56          Dividend equivalents under IRC section 871(m) as a result of 
     05       Interest on tax-free covenant bonds                                                 applying the combined transaction rules
     22       Interest paid on deposit with a foreign branch of a domestic            09          Capital gains
              corporation or partnership                                              10          Industrial royalties
     29       Deposit interest                                                        11          Motion picture or television copyright royalties
  Interest 30 Original issue discount (OID)                                           12          Other royalties (for example, copyright, software, 
     31       Short-term OID                                                                      broadcasting, endorsement payments)
     33       Substitute payment—interest                                             13          Royalties paid on certain publicly offered securities1
     51       Interest paid on certain actively traded or publicly offered            Other 14    Real property income and natural resources royalties
              securities1                                                             15          Pensions, annuities, alimony, and/or insurance premiums
     54       Substitute payments—interest from certain actively traded               16          Scholarship or fellowship grants
              or publicly offered securities1                                         17          Compensation for independent personal services2
     06       Dividends paid by U.S. corporations—general                             18          Compensation for dependent personal services2
     07       Dividends qualifying for direct dividend rate                           19          Compensation for teaching2
  Dividend 08 Dividends paid by foreign corporations
                                                                                                                                See back of Copy C for additional codes
1 This code should only be used if the income paid is described in Regulations section 1.1441-6(c)(2) and the withholding agent has reduced the rate of withholding under an 
income tax treaty without the recipient providing a U.S. or foreign TIN.
2 If compensation that otherwise would be covered under Income Codes 17 through 20 is directly attributable to the recipient  occupation’sas an artist or athlete, use 
Income Code 42 or 43 instead.

                            Foreign Person’s U.S. Source Income Subject to Withholding                                                                               OMB No. 1545-0096
Form 1042-S                     Go to www.irs.gov/Form1042S for instructions and the latest information.                            2024                                               for Recipient 
Department of the Treasury                                                                                                                                          Copy C 
Internal Revenue Service                                        UNIQUE FORM IDENTIFIER                         AMENDED             AMENDMENT NO.                 Attach to any Federal tax return you file
1 Income  2  Gross income   3   Chapter indicator.  Enter “3” or “4”                                      13e  Recipient’s U.S. TIN, if any              13f  Ch. 3 status code
  code
                            3a Exemption code             4a Exemption code                                                                              13g Ch. 4 status code
                            3b Tax rate            .      4b Tax rate      .                              13h  Recipient’s GIIN     13i  Recipient ’sforeign tax identification13j  LOB code 
                                                                                                                                            number, if any
5  Withholding allowance
6  Net income
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 
    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
10  Total withholding credit (combine boxes 7a, 8, and 9)                                                                                                15  Check if pro-rata basis reporting 
                                                                                                          15a  Intermediary or flow-through entity’s EIN, if any 15b Ch. 3 status code 15c Ch. 4 status code
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 code12c  Ch. 4 status code
                                                                                                          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

12i  City or town, state or province, country, ZIP or foreign postal code                                 16c  Payer’s GIIN                              16d Ch. 3 status code16e Ch. 4 status code

13a  Recipient’s name                          13b  Recipient’s country code                              17a  State income tax withheld    17b  Payer’s state tax no.    17c  Name of state

13c  Address (number and street)

13d  City or town, state or province, country, ZIP or foreign postal code

                                                                                                                                                                          Form 1042-S (2024)

Explanation of Codes (continued)                                                              04  Exempt under tax treaty
          20 Compensation during studying and training2                                       05  Portfolio interest exempt under IRC
          23 Other income                                                                     06  QI that assumes primary withholding responsibility
          24 Qualified investment entity (QIE) distributions of capital                       07  WFP or WFT
             gains                                                                            08  U.S. branch treated as U.S. Person
          25 Trust distributions subject to IRC section 1445                                  10  QI represents that income is exempt
          26 Unsevered growing crops and timber distributions by a trust                      11  QSL that assumes primary withholding responsibility
             subject to IRC section 1445                                                      12  Payee subjected to chapter 4 withholding
          27 Publicly traded partnership distributions subject to IRC                         22  QDD that assumes primary withholding responsibility
             section 1446(a)                                                                  23  Exempt under section 897(l)
          28 Gambling winnings3                                                               24  Exempt under section 892
          32 Notional principal contract income4                                       Chapter 4
          35 Substitute payment—other                                                         13  Grandfathered payment
          36 Capital gains distributions                                                      14  Effectively connected income
     Other
          37 Return of capital                                                                15  Payee not subject to chapter 4 withholding
          38 Eligible deferred compensation items subject to IRC section                      16  Excluded nonfinancial payment
             877A(d)(1)                                                                       17  Foreign Entity that assumes primary withholding 
          39 Distributions from a nongrantor trust subject to IRC section                         responsibility
             877A(f)(1)                                                                       18  U.S. Payees—of participating FFI or registered deemed-
          41 Guarantee of indebtedness                                                            compliant FFI
          42 Earnings as an artist or athlete—no central withholding                          19  Exempt from withholding under IGA8
             agreement5                                                                       20  Dormant account9
          43 Earnings as an artist or athlete—central withholding                             21  Other—payment not subject to chapter 4 withholding
             agreement5
                                                                                       Boxes 12b, 12c, 13f, 13g, 15b, 15c, 16d, and 16e.  Withholding 
          44 Specified federal procurement payments                                    Agent, Recipient, Intermediary, and Payer Chapter 3 and Chapter 
          50 Income previously reported under escrow procedure6                        4 Status Codes.
          55 Taxable death benefits on life insurance contracts                        Type of Recipient, Withholding Agent, Payer, or Intermediary
          57 Amount realized under IRC section 1446(f)                                     Code
          58 Publicly traded partnership distributions—undetermined                    Chapter 3  Status Codes
Boxes 3a and 4a. Exemption Code (applies if the tax rate entered                              05  U.S. branch—treated as U.S. Person10
in box 3b or 4b is 00.00).                                                                    06  U.S. branch—not treated as U.S. Person11
   Code                 Authority for Exemption                                               07  U.S. branch—ECI presumption applied
Chapter 3                                                                                     08  Partnership other than Withholding Foreign Partnership or 
          01 Effectively connected income                                                         Publicly Traded Partnership
          02 Exempt under IRC7                                                                09  Withholding Foreign Partnership
          03 Income is not from U.S. sources                                                                                     See back of Copy D for additional codes
2 If compensation that otherwise would be covered under Income Codes 17 through 20 is directly attributable to the recipient’s occupation as an artist or athlete, use 
Income Code 42 or 43 instead.
3 Subject to 30% withholding rate unless the recipient is from one of the treaty countries listed underGambling winnings (Income Code 28) in Pub. 515.
4 Use appropriate Interest Income Code for embedded interest in a notional principal contract.
5 Income Code 43 should only be used if Letter 4492, Venue Notification, has been issued by the Internal Revenue Service (otherwise, use Income Code 42 for earnings 
as an artist or athlete). If Income Code 42 or 43 is used, Recipient Code 22 (artist or athlete) should be used instead of Recipient Code 16 (individual), 15 (corporation), 
or 08 (partnership other than withholding foreign partnership or publicly traded partnership).
6 Use only to report gross income the tax for which is being deposited in the current year because such tax was previously escrowed for chapters 3 and 4 and the 
withholding agent previously reported the gross income in a prior year and checked the box to report the tax as not deposited under the escrow procedure. See the 
instructions to this form for further explanation.
7 This code should only be used if no other specific chapter 3 exemption code applies. 
8 Use only to report a U.S. reportable account or nonconsenting U.S. account that is receiving a payment subject to chapter 3 withholding. 
9 Use only if applying the escrow procedure for dormant accounts under Regulations section 1.1471-4(b)(6). If tax was withheld and deposited under chapter 3, do not 
check box 7b (“tax not deposited with IRS pursuant to escrow procedure”). You must instead enter “3” in box 3 and complete box 3b.
10 This code can be used by a Territory FI that is treated as a U.S. person.
11 This code can be used by a Territory FI that is not treated as a U.S. person.

                            Foreign Person’s U.S. Source Income Subject to Withholding                                                                               OMB No. 1545-0096
Form 1042-S                     Go to www.irs.gov/Form1042S for instructions and the latest information.                            2024                                               for Recipient 
Department of the Treasury                                                                                                                                          Copy D 
Internal Revenue Service                                        UNIQUE FORM IDENTIFIER                         AMENDED             AMENDMENT NO.                    Attach to any state tax return you file
1 Income  2  Gross income   3   Chapter indicator.  Enter “3” or “4”                                      13e  Recipient’s U.S. TIN, if any              13f  Ch. 3 status code
  code
                            3a Exemption code             4a Exemption code                                                                              13g Ch. 4 status code
                            3b Tax rate            .      4b Tax rate      .                              13h  Recipient’s GIIN     13i  Recipient ’sforeign tax identification13j  LOB code 
                                                                                                                                            number, if any
5  Withholding allowance
6  Net income
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 
    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
10  Total withholding credit (combine boxes 7a, 8, and 9)                                                                                                15  Check if pro-rata basis reporting 
                                                                                                          15a  Intermediary or flow-through entity’s EIN, if any 15b Ch. 3 status code 15c Ch. 4 status code
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 code12c  Ch. 4 status code
                                                                                                          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

12i  City or town, state or province, country, ZIP or foreign postal code                                 16c  Payer’s GIIN                              16d Ch. 3 status code16e Ch. 4 status code

13a  Recipient’s name                          13b  Recipient’s country code                              17a  State income tax withheld    17b  Payer’s state tax no.    17c  Name of state

13c  Address (number and street)

13d  City or town, state or province, country, ZIP or foreign postal code

                                                                                                                                                                          Form 1042-S (2024)

Explanation of Codes (continued)                                                           19   Passive NFFE identifying Substantial U.S. Owners
   10   Trust other than Withholding Foreign Trust                                         20   Passive NFFE with no Substantial U.S. Owners
   11   Withholding Foreign Trust                                                          21   Publicly Traded NFFE or Affiliate of Publicly Traded NFFE
   12   Qualified Intermediary                                                             22   Active NFFE
   13   Qualified Securities Lender—Qualified Intermediary                                 23   Individual
   14   Qualified Securities Lender—Other                                                  24   Section 501(c) Entities
   15   Corporation                                                                        25   Excepted Territory NFFE
   16   Individual                                                                         26   Excepted NFFE—Other
   17   Estate                                                                             27   Exempt Beneficial Owner
   18   Private Foundation                                                                 28   Entity Wholly Owned by Exempt Beneficial Owners
   19   International Organization                                                         29   Unknown Recipient
   20   Tax Exempt Organization (Section 501(c) entities)                                  30   Recalcitrant Account Holder
   21   Unknown Recipient                                                                  31   Nonreporting IGA FFI
   22   Artist or Athlete                                                                  32   Direct reporting NFFE
   23   Pension                                                                            33   U.S. reportable account
   24   Foreign Central Bank of Issue                                                      34   Nonconsenting U.S. account
   25   Nonqualified Intermediary                                                          35   Sponsored direct reporting NFFE
   26   Hybrid entity making Treaty Claim                                                  36   Excepted Inter-affiliate FFI
   35   Qualified Derivatives Dealer                                                       37   Undocumented Preexisting Obligation
   36   Foreign Government—Integral Part                                                   38   U.S. Branch—ECI presumption applied
   37   Foreign Government—Controlled Entity                                               39   Account Holder of Excluded Financial Account13
   38   Publicly Traded Partnership                                                        40   Passive NFFE reported by FFI14
   39   Disclosing Qualified Intermediary                                                  41   NFFE subject to 1472 withholding
 Pooled Reporting Codes12                                                                  50   U.S. Withholding Agent—Foreign branch of FI
   27   Withholding Rate Pool—General                                                   Pooled Reporting Codes
   28   Withholding Rate Pool—Exempt Organization                                          42   Recalcitrant Pool—No U.S. Indicia
   29   PAI Withholding Rate Pool—General                                                  43   Recalcitrant Pool—U.S. Indicia
   30   PAI Withholding Rate Pool—Exempt Organization                                      44   Recalcitrant Pool—Dormant Account
   31   Agency Withholding Rate Pool—General                                               45   Recalcitrant Pool—U.S. Persons
   32   Agency Withholding Rate Pool—Exempt Organization                                   46   Recalcitrant Pool—Passive NFFEs
Chapter 4 Status Codes                                                                     47   Nonparticipating FFI Pool
   01   U.S. Withholding Agent—FI                                                          48   U.S. Payees Pool
   02   U.S. Withholding Agent—Other                                                       49   QI-Recalcitrant Pool—GeneraI15
   03   Territory FI—not treated as U.S. Person                                        Box 13j. LOB Code (enter the code that best describes the 
   04   Territory FI—treated as U.S. Person                                            applicable limitation on benefits (LOB) category that qualifies the 
   05   Participating  FFI—Other                                                       taxpayer for the requested treaty benefits).
   06   Participating  FFI—Reporting Model 2 FFI                                       LOB Code                    LOB Treaty Category
   07   Registered Deemed-Compliant FFI—Reporting Model 1 FFI                              02   Government – contracting state/political subdivision/local 
   08   Registered Deemed-Compliant FFI—Sponsored Entity                                        authority
   09   Registered Deemed-Compliant FFI—Other                                              03   Tax exempt pension trust/Pension fund
   10   Certified Deemed-Compliant FFI—Other                                               04   Tax exempt/Charitable organization
   11   Certified Deemed-Compliant FFI—FFI with Low Value                                  05   Publicly traded corporation
        Accounts                                                                           06   Subsidiary of publicly traded corporation
   12   Certified Deemed-Compliant FFI—Nonregistering Local                                07   Company that meets the ownership and base erosion test
        Bank                                                                               08   Company that meets the derivative benefits test
   13   Certified Deemed-Compliant FFI—Sponsored Entity                                    09   Company with an item of income that meets the active trade 
   14   Certified Deemed-Compliant FFI—Investment Entity that                                   or business test
        does not maintain financial accounts                                               10   Discretionary determination
   15   Nonparticipating FFI                                                               11   Other
   16   Owner-Documented FFI                                                               12   No LOB article in treaty
   17   U.S. Branch—treated as U.S. person
   18   U.S. Branch—not treated as U.S. person (reporting under 
        section 1471)
12 Codes 27 through 32 should only be used by a QI, QSL, WP, or WT. A QI acting as a QDD may use only code 27 or 28.
13 This code should only be used if income is paid to an account that is excluded from the definition of financial account under Regulations section 1.1471-5(b)(2) or 
under Annex II of the applicable Model 1 IGA or Model 2 IGA.
14 This code should only be used when the withholding agent has received a certification on the FFI withholding statement of a participating FFI or registered deemed-
compliant FFI that maintains the account that the FFI has reported the account held by the passive NFFE as a U.S. account (or U.S. reportable account) under its 
FATCA requirements. The withholding agent must report the name and GIIN of such FFI in boxes 15d and 15e.
15 This code should only be used by a withholding agent that is reporting a payment (or portion of a payment) made to a QI with respect to the QI’s recalcitrant account holders.