(a) (b) (c) (d) (e/f) (g) (h) Income from Foreign Sources (See Instructions) Attach Applicable Forms to Substantiate Foreign Tax Withholdings or Payments Form 1041NR (2007) Page 7 (a) (b) (c) (d) (e/f) (g) (h) Foreign Foreign Gross Gross Income Exempt Taxable Allocable Nature of Income Country of Tax Paid Tax Income Income Under US Tax Treaty Gross Expenses to (Generally Under IRC Sec. 862) Source of in Foreign Converted to in Foreign Converted to Treaty/ Provision Income Taxable Income Currency US Dollars Currency US Dollars Country Cited (d) Less (f) Income 1 Dividends paid by: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . Interest: a) Mortgage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . b) Paid by foreign corporations . . . . . . . . . . . . . . . . . . . . . . . . . c) Other (Describe in attached Schedule). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 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 18 below). . . . . . . . . . . . . . . . . Other (specify) ► - US corporations 1a Foreign corporations 1b 2 2a 2b 2c 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10 11 Total foreign tax withheld at source. . . . . . . . . . . . . . . . . . . 11 12 If a “Simple” or “Grantor Trust”: 12a a) If election made to claim deduction of foreign tax, enter total on Line 12, Page 1………… . . . . . . . . . . . . . . . . . . . b) If election made to claim foreign tax credit,” enter total 12b in Part II, Page 1, Form 1116………………. . . . . . . . . . . . . . 13 Add Line 1a through 10 in Columns (d) through (h)………… 13 13 13 13 13 14 If a “Non-Grantor” or Complex Trust or Estate paying no 14 14 14 14 14 “current year” income distributions (See Instructions). . . . . . . 15 Net “Foreign Taxable Income: Line 13(g) less (h). Enter total 15 here and on Form 1041NR, Line 8, Page 1…….. . . . . . . . . . . . . Capital Gains and Losses from Sales or Exchanges of Property (Converted to US Dollars) (f) LOSS (g) GAIN Enter only the capital gains 16 (a) Kind of property and description (b) Date (c) Date (e) Cost or other and losses from property sales (if necessary, attach statement of Acquired sold (d) Sales price If (e) is more If (d) is more than (d), subtract than (e), subtract or exchanges that are from descriptive details not shown below) (mo., day, yr.) (mo., day, yr.) basis (d) from (e). (e) from (d). sources without 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 16. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . exchanges that are effectively 17 17 connected with a US business on Schedule D (Form 1041NR), Form 4797, or both. 18 Capital gain. Combine Columns (f) and (g) of Line 17. Enter the net gain here and on Line 9 above (if a loss, enter 0) . .…. ..►18 Form 1041NR (2007)