Form 1040NR (2009), Page 4

Summary: This is an example of Form 1040NR (2009), page 4, with items included as described in the text. Additionally, these line items are completed:

76a. Dividends paid by: U.S. corporations (c) 15% field contains 240
86. Total U.S. tax withheld at source. Add column (a) of lines 765a through 85. Enter the total here and on Form 1040NR, line 66 field contains 36
87. Add lines 76a through 85 in columns (b)-(e): (c) 15% field contains 240
88. Multiply line 87 by rate of tax at top of each column field contains 36
89. Tax on income not effectively connected with a U.S. trade or business. Add columns (b)-(e) of line 88. Enter the total here and on Form 1040NR, line 53 field contains 36

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