RR Donnelley 2012 Tax Forms : Page 13

LASER FORMS 1 0 9 6 , 1 0 4 2 S , 3 9 2 1 , 3 9 2 2 , 1 0 9 9 K L a s e r F o r m s a n d 1 0 9 9 K i t s 1096 Do Not Staple 1042S 12 OMB No. 1545-0108 3921 6969 Form 1096 FILER’S name Department of the Treasury Internal Revenue Service Annual Summary and Transmittal of U.S. Information Returns Form 1042-S 12 Foreign Person’s U.S. Source Income Subject to Withholding AMENDED 3 Withholding allowances 4 Net income 5 Tax rate 6 Exemption code Department of the Treasury Internal Revenue Service 12 7 Federal tax withheld 9 Total withholding credit OMB No. 1545-0096 PRO-RATA BASIS REPORTING Copy A for Internal Revenue Service 1 Income 2 Gross income code 8 Withholding by other agents 10 Amount repaid to recipient 14 15 17 Recipient’s U.S. TIN, if any QI-EIN EIN SSN or ITIN Recipient’s foreign tax identifying number, if any 16 Country code NQI’s/FLOW-THROUGH ENTITY’S name 18 Country code Street address (including room or suite number) 11 Withholding agent’s EIN QI-EIN EIN 12a WITHHOLDING AGENT’S name Telephone number Fax number 2 Social security number 3 Total number of forms 4 Federal income tax withheld 5 Total amount reported with this Form 1096 City, state, and ZIP code Name of person to contact Email address 1 Employer identification number For Official Use Only DETACH BEFORE MAILING 12b Address (number and street) 12c Additional address line (room or suite no.) 12d City or town, province or state, country, ZIP or foreign postal code 13a RECIPIENT’S name 13c Address (number and street) 13d Additional address line (room or suite no.) 13e City or town, province or state, country, ZIP or foreign postal code 19a NQI’s/Entity’s address (number and street) 19b Additional address line (room or suite no.) 19c City or town, province or state, country, ZIP or foreign postal code NQI’s/Entity’s U.S. TIN, if any PAYER’S name and TIN (if different from withholding agent’s) Recipient account number (optional) State income tax withheld 24 Payer’s state tax no. 25 Name of state FOR 011! Item No. AS 2 50 Sheets/Pk (150 Forms/Pk) Description L 3 9 21 A Federal – Copy A SAME MAT $ 6 Enter an “X” in only one box below to indicate the type of form being filed. W-2G 32 1097-BTC 50 1098 81 1098-C 78 1098-E 84 1098-T 83 1099-A 80 1099-B 79 1099-C 85 1099-CAP 73 $ . . 1099-INT 92 1099-DIV 91 1099-G 86 1099-H 71 7 If this is your final return , enter an “X” here . 13b Recipient code 20 21 22 23 DETACH BEFORE MAILING 12 1099-K 10 1099-LTC 93 1099-MISC 95 1099-OID 96 1099-PATR 97 1099-Q 31 1099-R 98 1099-S 75 1099-SA 94 3921 25 3922 26 5498 28 5498-ESA 72 5498-SA 27 L 3 9 21 B L 3 9 21 C L 3 9 21 D Employee – Copy B Corporation – Copy C Transferor – Copy D For Privacy Act and Paperwork Reduction Act Notice, see instructions. Form 1042-S (2012) Return this entire page to the Internal Revenue Service. Photocopies are not acceptable. Under penalties of perjury, I declare that I have examined this return and accompanying documents, and, to the best of my knowledge and belief, they are true, correct, and complete. Signature Title Date Form 1042-S Instructions Reminder. The only acceptable method of filing information returns with Internal Revenue Service/Information Returns Branch is electronically through the FIRE system. See Pub. 1220, Specifications for Filing Forms 1097, 1098, 1099, 3921, 3922, 5498, 8935, and W-2G Electronically. Purpose of form. Use this form to transmit paper Forms 1097, 1098, 1099, 3921, 3922, 5498, and W-2G to the Internal Revenue Service. Do not use Form 1096 to transmit electronically. For electronic submissions, see Pub. 1220. Caution: If you are required to file 250 or more information returns of any one type, you must file electronically. If you are required to file electronically but fail to do so, and you do not have an approved waiver, you may be subject to a penalty. For more information, see part F in the 2012 General Instructions for Certain Information Returns. Who must file. The name, address, and TIN of the filer on this form must be the same as those you enter in the upper left area of Forms 1097, 1098, 1099, 3921, 3922, 5498, or W-2G. A filer is any person or entity who files any of the forms shown in line 6 above. 1B-L6 When to file. File Form 1096 as follows. Foreign Person’s U.S. Source Income Subject to Withholding AMENDED 3 Withholding allowances 4 Net income 5 Tax rate 6 Exemption code • • With Forms 1097, 1098, 1099, 3921, 3922, or W-2G, file by February 28, 2013. With Form 5498, file by May 31, 2013. Department of the Treasury Internal Revenue Service 12 7 Federal tax withheld 9 Total withholding credit OMB No. 1545-0096 PRO-RATA BASIS REPORTING Copy A for Internal Revenue Service 3922 12 1 Income 2 Gross income code 8 Withholding by other agents Where To File Send all information returns filed on paper with Form 1096 to the following: 10 Amount repaid to recipient 11 Withholding agent’s EIN QI-EIN EIN 12a WITHHOLDING AGENT’S name 12b Address (number and street) 12c Additional address line (room or suite no.) 12d City or town, province or state, country, ZIP or foreign postal code 13a RECIPIENT’S name 1A/L483 14 15 17 Recipient’s U.S. TIN, if any QI-EIN EIN SSN or ITIN Recipient’s foreign tax identifying number, if any 16 Country code NQI’s/FLOW-THROUGH ENTITY’S name 18 Country code If your principal business, office or agency, or legal residence in the case of an individual, is located in Use the following three-line address 19a NQI’s/Entity’s address (number and street) 19b Additional address line (room or suite no.) 19c City or town, province or state, country, ZIP or foreign postal code NQI’s/Entity’s U.S. TIN, if any PAYER’S name and TIN (if different from withholding agent’s) Recipient account number (optional) State income tax withheld 24 Payer’s state tax no. 25 Name of state Alabama, Arizona, Arkansas, Connecticut, Delaware, Florida, Georgia, Kentucky, Louisiana, Maine, Department of the Treasury Massachusetts, Mississippi, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Internal Revenue Service Center Austin, TX 73301 Ohio, Pennsylvania, Rhode Island, Texas, Vermont, Virginia, West Virginia 13b Recipient code 20 21 22 23 Enter the filer’s name, address (including room, suite, or other unit number), and TIN in the spaces provided on the form. 13c Address (number and street) 13d Additional address line (room or suite no.) 13e City or town, province or state, country, ZIP or foreign postal code For more information and the Privacy Act and Paperwork Reduction Act Notice, see the 2012 General Instructions for Certain Information Returns. NEW T A FORM 012! 2 Forms/Sheet 2 R FO L1042SA-12 Form 1096 (2012) For Privacy Act and Paperwork Reduction Act Notice, see instructions. NEW T A FORM 012! 1 Form/Sheet 2 R FO L1042S3UP-12 Form 1042-S (2012) SAME AT FORM 011! 2 S A Item No. FORM 011! AS 2 50 Sheets/Pk (150 Forms/Pk) Description L 3 9 22 A Federal – Copy A L 3 9 22 B Employee – Copy B L 3 9 22 C Corporation – Copy C SAME AT FORM # L1096 FORM # L1042SA-12 8403000022 1A-L5 8903006345 1099K Item No. 50 Sheets/Pk (50 Forms/Pk) Description L 1 0 9 6 1096 Summary & Transmittal of Returns Item No. BULK 2000 Sheets/Ctn (2000 Forms/Ctn) Description L 1 0 9 6 B U L K 1096 Summary & Transmittal of Returns Packaging Item No. Description 50 Sheets/Pk (100 Forms/Pk) L1 0 4 2S A -1 2 /-1 3 L1 0 4 2S B -1 2 /-1 3 L1 0 4 2S C -1 2 /-1 3 L1 0 4 2S D -1 2 /-1 3 L1 0 4 2S E -1 2 / -13 L 1 0 4 2 S 3 U P -1 2 / -13 * Withholding Agent’s Federal – Copy A Recipient’s Record – Copy B Recipient’s Federal – Copy C Recipient’s State – Copy D Withholding Agent’s Record – Copy E Recipient’s Copies B, C, D FORM Item No. 011! AS 2 50 Sheets/Pk (100 Forms/Pk) Description L K A Federal – Copy A SAME AT L K B L K C Payee – Copy B Filer – Copy C Must choose either 2012 or 2013 when ordering *50 Forms Per Pack Foreign Person’s U.S. Source Income Subject to Withholding Form 1096 is used for transmittal and summary of 1098, 1099, and 5498 forms, when these forms are submitted on paper to the IRS. M a t c h i n g E n v e l o p e s 1042SENVB Important Tax Return Document Enclosed L1042SENVB Important Tax Return Document Enclosed Important Tax Return Document Enclosed Important Tax Return Document Enclosed 7545ES 7950862 7535ES 7956E Item No. Description 1 0 4 2 SE N V B Single Window Envelope L 1 04 2 S E NV B Single Window Envelope For L1042S3UP Only 7 9 5 0 86 2 Double Window Envelope for 3921 and 3922 7 9 5 6 E Double Window Envelope For 1099K Only 1 0 9 9 T a x F o r m K i t s Kit Description 100 Forms of each Copy A, B, C, State Copy and 100 Double Window Envelopes (7956E) LM IS C 5 100 Forms of each Copy A, B, C/State (2), Copy 2 and 100 Double Window Envelopes (7956E) LI N T4 150 Forms of each Copy A, B, C, State Copy and 150 Double Window Envelopes (7950862) LD IV 4 100 Forms of each Copy A, B, C, State Copy and 100 Double Window Envelopes (7956E) L1 0 9 84 150 Forms of each Copy A, B, C, State Copy and 150 Double Window Envelopes (7950862) LR 6 100 Forms of each Copy A, B, C, D, 1, 2, and 100 Double Window Envelopes (7956E) All kits include 1096 transmittal form Item No. LM IS C 4 Equivalent To: One hundred 4-Part 1099 MISC One hundred 5-Part 1099 MISC One hundred & fifty 4-Part 1099 INT One hundred 4-Part 1099 DIV One hundred & fifty 4-Part 1098 One hundred 6-Part 1099R We will include every copy you need to file 150 tax forms (100 copies if filing forms 1099R, 1099MISC, or 1099DIV). Each kit contains the Federal, State, Recipient and your file copies, plus double window envelopes for your recipient copies. All our laser forms are made from premium laser paper to run smoothly and prevent jamming. Sheets measure 81⁄2" x 11". All kits include envelopes. All sheets on this page are 8 1 ⁄ 2 " x 11". NOTE: All forms on this page contain one employee per sheet. 13

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