1. Income from Foreign Sources (See Instructions) Attach Applicable Forms to Substantiate Foreign Tax Withholdings or Payments Form 1041NR (2007) Page 7 Nature of Income 1 Dividends paid by: a)............................................. b).............................................. 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) ► - 2 3 Total foreign tax withheld at source................... 4 5 6 7 8 9 10 11 12 Capital Gains and Losses from Sales or Exchanges of Property (Converted to US Dollars) Enter only the capital gains 16 (a) Kind of property and description (if necessary, attach statement of descriptive details not shown below ) (b) Date Acquired (mo., day, yr.) ( d) Sales price ( c) Date sold (mo., day, yr.) ( e) Cost or other basis (f) LOSS If (e) is more than (d), subtract (d) from (e). (g) GAIN If (d) is more than (e), subtract (e) from (d). and losses from property sales or exchanges that are from 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 exchanges that are effectively connected with a US business on Schedule D (Form 1041NR), Form 4797, or both. 17 Add Columns (f) and (g) of Line 16............................................................. 17 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) (a) (b) (c) (d) (e/f) (g) (h) Foreign Foreign Gross Gross Income Exempt Taxable Allocable Tax Paid Tax Income Income Under US Tax Treaty Gross Expenses to in Foreign Currency Converted to US Dollars in Foreign Currency Converted to US Dollars Treaty/ Country Provision Cited Income (d) Less (f) Taxable Income Source of Country of (Generally Under IRC Sec. 862) If a “Simple” or “Grantor Trust”: 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 in Part II, Page 1, Form 1116 ……………….............. Add Line 1a through 10 in Columns (d) through (h)…………13 If a “Non-Grantor” or Complex Trust or Estate paying no “current year” income distributions (See Instructions)....... 14 Net “Foreign Taxable Income: Line 13(g) less (h). Enter total here and on Form 1041NR, Line 8, Page 1…….............. 15 11 12a 13 14 15 1a US corporations Foreign corporations 1b 2a 2b 2c 3 4 5 6 7 8 9 10 12b 13