SCHEDULE Q
(Form 1042)
2021
Tax Liability of Qualified Derivatives Dealer (QDD)
Department of the Treasury
Internal Revenue Service
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Attach to Form 1042.
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Go to www.irs.gov/Form1042 for the latest information.
OMB No. 1545-0096
Name of taxpayer Employer identification number
Name of QDD QI-EIN
QDD Tax Year (enter month, day, and year for beginning and ending dates)
Beginning , 20 , and ending , 20
.
Indicate the year or portion of the year to which the schedule relates (enter month, day, and year beginning
and ending dates)
Beginning , 20 , and ending , 20
.
Schedule of
Summary of QDD Tax Liability
(a)
Gross Amount
(b)
Withholding
Tax Rate
(c)
Amount of
Tax Liability (column
(a) x column (b))
1 Total section 871(m) amount . . . . . . . . . . . . 1
2 Total dividends received in equity derivatives dealer capacity . .
2
3 Total QDD tax liability pursuant to section 3.09(A) of the Qualified
Intermediary Agreement . . . . . . . . . . . . . . 3
4 Total QDD tax liability pursuant to section 3.09(B) of the Qualified
Intermediary Agreement . . . . . . . . . . . . . . 4
5 Total QDD tax liability pursuant to section 3.09(C) of the Qualified
Intermediary Agreement:
a
Income Type
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5a
b
Income Type
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5b
c
Income Type
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5c
d
Income Type
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5d
6 Total of line 5 amounts . . . . . . . . . . . . . . 6
Who Must File
If the taxpayer or any branch of the taxpayer was a qualified
derivatives dealer (QDD) (defined below) during the tax year,
Schedule Q must be completed and filed for each of those QDDs.
The taxpayer must file Schedule Q as an attachment to Form 1042
even if the QDD has zero tax liability.
Qualified derivatives dealer (QDD). A QDD is a home office or
branch that, in accordance with the qualified intermediary
agreement (QIA) (defined below), qualifies and has been approved
for QDD status and satisfies the requirements of the QIA. See the
QIA for additional information.
Qualified intermediary agreement (QIA). The QIA is section 6 of
Rev. Proc. 2017-15.
General Instructions
A separate Schedule Q is required for each QDD. In addition, if a
taxpayer has a fiscal year rather than a calendar year, the taxpayer
must provide a separate Schedule Q for each QDD for each portion
of the fiscal year that falls within the calendar year.
Example. A QDD with a fiscal year beginning September 1 and
ending August 31 would complete 2 schedules. One for the period
of January 1, 2021, through August 31, 2021, and one for the period
of September 1, 2021, through December 31, 2021.
Specific Instructions
Name of QDD. The name of the QDD should follow the naming
protocol used for applying to be a QDD.
Number of schedules filed. A QDD may be required to file multiple
Schedules Q, for example, if it has multiple branches that are QDDs
or if it is a fiscal year taxpayer (as explained in General Instructions
above). Indicate the number of each Schedule Q filed, as well as the
total number of Schedules Q being filed by the taxpayer in the entry
spaces provided.
Column (c), Amount of Tax Liability. Except as provided in the
Note immediately below, the amount in column (c) is determined by
multiplying column (a) by column (b). This column is not reduced by
any withholding that has occurred.
Note: For calendar years 2018 through 2022, certain information is
not required, as indicated in the line instructions below. However, if
the taxpayer has a fiscal year rather than a calendar year, that
begins in 2022, information is required for any amounts paid or
accrued on or after January 1, 2023.
Line 1. The gross amount to be entered in column (a) is the sum of
each section 871(m) amount for the QDD for the relevant period.
See section 2.73 of the QIA for the definition of section 871(m)
amount.
Note: For calendar years 2019 through 2022, this information is not
required.
Line 2. For calendar years 2019 through 2022, only the gross
amount (column (a)) and tax rate (column (b)) are required.
Line 3. Column (c) is the sum of each section 3.09(A) amount for the
QDD for the relevant period.
Note: For calendar years 2019 through 2022, this information is not
required.
Line 4. Enter the information requested in columns (a), (b), and (c).
Line 5. In addition to specifying the type of income (for example,
dividends or interest), enter the information requested in columns
(a), (b), and (c) separately for each income type. For dividends,
include all dividends, including dividends separately stated on
line 2.
Note: For calendar years 2019 through 2022, do not include
dividends included in line 2.
For Paperwork Reduction Act Notice, see the Instructions for Form 1042.
Cat. No. 71805T Schedule Q (Form 1042) 2021
