1. 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 b
c Other c
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) ► 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 ► 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
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)