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Form 1040NR (2005), Page 4. Summary: This is an example of Form 1040NR (2005), page 4, with items included as described in the text. Additionally, these line items are completed:

75a. Dividends paid by: U.S. corporations (c) 15%” field contains 240
85. Total U.S. tax withheld at source. Add column (a) of lines 75a through 84. Enter the total here and on Form 1040NR, line 66” field contains 36
86. Add lines 75a through 84 in columns (b)-(e): (c) 15%” field contains 240
87. Multiply line 86 by rate of tax at top of each column” field contains 36
88. Tax on income not effectively connected with a U.S. trade or business. Add columns (b)-(e) of line 87. Enter the total here and on Form 1040NR, line 53” field contains 36