Tax on Income Not Effectively Connected With a US Trade or Business

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Tax on Income Not Effectively Connected With a US Trade or Business Form 1041NR (2007) Page 6 Attach Forms 1042-S, SSA-1042S, RRB-1042S, or similar form. (a) US tax Enter amount of income under the appropriate rate of tax. (See Instructions, Page 2.) Nature of Income withheld (e) Other (specify) at source (b) 10% (c) 15% (d) 30% % % 1 Dividends paid by: a US corporations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b Foreign corporations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Interest: a Mortgage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b Paid by foreign corporations . . . . . . . . . . . . . . . . . . . . . . . . . 2b c Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2c Industrial royalties (patents, trademarks, etc.) . . . . . . . . . . . . . . 3 Motion picture or TV copyright royalties. . . . . . . . . . . . . . . . . . 4 Other royalties (copyrights, recording, publishing, etc). . . . . . . . Real property income and natural resources royalties. . . . . . . . . 6 Pensions and annuities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . Social security benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gains (include capital gain from 17 below). . . . . . . . . . . . . . . . Other (specify) ► 1a 1b 2 2a 3 4 5 5 6 7 7 8 8 9 9 10 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 Enter only the capital gains 15 (a) Kind of property and description (b) Date (c) Date (e) Cost or other If (e) is more If (d) is more and losses from property sales (if necessary, attach statement of Acquired sold (d) Sales price (mo., day, yr.) basis than (d), subtract than (e), subtract 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 Add Columns (f) and (g) of Line 15. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . exchanges that are effectively 16 16 connected with a US business on Schedule D (Form 1041NR), Form 4797, or both. 17 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)