Form 1041NR (2007)
Page 6
Tax on Income Not Effectively Connected With a US Trade or Business
Attach Forms 1042-S, SSA-1042S, RRB-1042S, or similar form.
(a) US tax
withheld
at source
Nature of Income
1
2
3
4
5
6
7
8
9
10
Dividends paid by:
a US corporations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b Foreign corporations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Interest:
a Mortgage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b Paid by foreign corporations . . . . . . . . . . . . . . . . . . . . . . . . .
c Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Industrial royalties (patents, trademarks, etc.) . . . . . . . . . . . . . .
Motion picture or TV copyright royalties. . . . . . . . . . . . . . . . . .
Other royalties (copyrights, recording, publishing, etc). . . . . . . .
Real property income and natural resources royalties. . . . . . . . .
Pensions and annuities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .
Social security benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Gains (include capital gain from 17 below). . . . . . . . . . . . . . . .
Other (specify) ►
Enter amount of income under the appropriate rate of tax. (See Instructions, Page 2.)
(b) 10%
(c) 15%
(d) 30%
(e) Other (specify)
%
%
1a
1b
2a
2b
2c
3
4
5
6
7
8
9
10
11 Total US tax withheld at source. Add Column (a) of Lines
1a through 10. Enter the total here and on Form 1041NR,
Line 25e, Page 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ► 11
12 Add Lines 1a through 10 in Columns (b)-(e). . . . . . . . . . . . . . . . . . . . . . . . . . . .. . 12
13 Multiply Line 12 by rate of tax at top of each column . . . . . . . . . . . . . . . . . . . 13
14 Tax on income not effectively connected with a US trade or business. Add Columns (b)-(e) of Line 13.
Enter the total here and on Form 1041NR, Line 2(d), Schedule C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ► 14
Capital Gains and Losses from Sales or Exchanges of Property
(f) LOSS
(g) GAIN
(c) Date
(b) Date
Enter only the capital gains 15 (a) Kind of property and description
(
e) Cost or other
If
(e)
is
more
If
(d) is more
sold
(d) Sales price
Acquired
and losses from property sales
(if necessary, attach statement of
than (d), subtract than (e), subtract
basis
(mo., day, yr.)
or exchanges that are from
descriptive details not shown below) (mo., day, yr.)
(d) from (e).
(e) from (d).
sources within the US and not
effectively connected with a US
business. Do not include a gain
or loss on disposing of a US real
property interest; report these
gains and losses on Schedule D
(Form 1041NR).
Report property sales or
16
exchanges that are effectively
connected with a US business on
Schedule D (Form 1041NR),
17
Form 4797, or both.
Add Columns (f) and (g) of Line 15. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Capital gain. Combine Columns (f) and (g) of Line 16. Enter the net gain here and on Line 9 above (if a loss, enter 0) . . . . ..► 17
Form 1041NR (2007)