Guide to Global Payroll Management - 2020 - D-113

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Appendix D--Federal Forms and Instructions

Appendix C (continued)
Box

Description

Required Entry

12b-c

Withholding agent's
chapter 3 and chapter 4
status code

"15" and "02"

12d
12e
12f

Withholding agent's
name

Withholding agent's
GIIN

"WA"

Withholding agent's
foreign tax identification
number, if any

12h-I

Withholding agent's
address

Specific
information
required

13b

Recipient's country
code

Specific
information
required

13c-d

Recipient's address

13e

Recipient's U.S. TIN, if
any

13f

Recipient's chapter 3
status code

"16"

13g

Recipient's chapter 4
status code

"23"

13h

Recipient's name

Recipient's GIIN

13i

Recipient's foreign tax
identification number, if
any

13k

Recipient's account
number

13j

13l

LOB code

Recipient's date of birth

14a-b

Primary withholding
agent's information

15a-I

Intermediary information

16a-e

Payer's information

17a-c

State income taxes

WA must enter its complete name.

WA leaves this box blank because a U.S. withholding agent is generally not required to
obtain a GIIN. See Global intermediary identification number and Box 12e, earlier, for details.

WA leaves Box 12f blank because it is a U.S. withholding agent (see the instructions for Box
12f, earlier).

Withholding agent's
country code

12g

13a

Comments

WA enters "15" in Box 12b and "02" in Box 12c because it is a U.S. corporate withholding
agent that is not a financial institution.
Note. WA must enter both a chapter 3 and a chapter 4 withholding agent status code
regardless of the type of payment being reported.

"A"

Specific
information
required

WA leaves this box blank because it is a U.S. withholding agent and it does not have an
FTIN or a country of residence other than the United States.
Although WA's address is not specified in this example, this is a required field that WA
would complete. See Boxes 12d Through 12i, earlier, for requirements.
WA enters the recipient's name.

Although the recipient's country of residency is not specified in this example, this is a
required field that WA would complete. See the instructions for Box 13b, earlier, for
requirements.

Although the recipient's address is not specified in this example, this is a required field that
WA would complete. See Boxes 13c and 13d for requirements.

The recipient's U.S. TIN is not specified in this example. However, given the facts used in
this example, the recipient's U.S. TIN is generally not required because A is not a type of
recipient described in the instructions for Boxes 13e and 13h, earlier, for which this TIN is
required (for example, A is not claiming a reduced rate of, or exemption from, tax under a tax
treaty between the recipient's country of residence and the United States). However, WA
must enter the recipient's U.S. TIN if WA knows it or if it was provided to WA on a Form W-8.
WA enters chapter 3 status code "16" (individual), which is the appropriate two-digit code
from the list of chapter 3 status codes provided in Appendix B.
Note. A withholding agent must enter a chapter 3 status code for all "amounts subject to
reporting under chapter 3."

WA enters chapter 4 status code "23" (individual), which is the appropriate two-digit code
from the list of chapter 4 status codes provided in Appendix B.
Note. A withholding agent must enter a chapter 4 status code for the recipient only if the
payment is a withholdable payment (as is the case in this example) or when a participating
FFI or registered deemed-compliant FFI is reporting a chapter 4 withholding rate pool of U.S.
payees.

WA leaves Box 13h blank because it only applies for chapter 4 reporting purposes. See
Global intermediary identification number and the instructions for Boxes 13e and 13h.

The recipient's FTIN is not required because A is not a type of recipient described in the
instructions for Box 13i for which the FTIN is required.

WA leaves Box 13j blank because the recipient is an individual (not an entity).
WA leaves Box 13k blank because WA is not a financial institution.
WA leaves Box 13l blank because WA is not a financial institution.

WA leaves these boxes blank because tax was not withheld by other withholding agents.

WA leaves these boxes blank because WA is making a direct payment to the recipient and
there are no other withholding agents.
WA leaves these boxes blank because WA is making a direct payment to the recipient and
there are no other payers involved.

Although not specified in this example, WA enters in these boxes any information relating to
any state income tax withheld.

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D-113

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