Appendix D-Federal Forms and Instructions Form 13930 (June 2018) Department of the Treasury - Internal Revenue Service Application for Central Withholding Agreement 1. Athlete/Entertainer (nonresident alien) AE-ID (IRS Use Only) a. Legal Name (last, first, middle initial) c. U.S. Taxpayer ID (SSN) b. Address d. Date of birth OMB Number 1545-2102 Date received (IRS Use Only) e. Country of residence f. Country of citizenship g. Applying as Athlete h. Group name (if applicable) i. Percentage share of net income j. Stage name k. Marital status Married l. Operating as business (LLC, corporation, partnership) Business name U.S. Taxpayer ID of Business Country where business established Entertainer Single Date business started Employer Identification Number (EIN) where 1042 deposits are being made 2. Withholding Agent WHA-ID (IRS Use Only) a. Firm d. U.S. Taxpayer ID (EIN/SSN) b. Contact person e. Voice phone number c. Address f. Fax phone number g. All CWA Deposits are required to be made using EFTPS. Are you currently enrolled in EFTPS CWA-ID (IRS Use Only) Yes No h. I am acting as Promoter Agent Venue Other I declare that I have examined under penalties of perjury and to the best of my knowledge and belief, the statements are true, correct, and complete. Signature Date *Must be signed by each NRA on application unless signed by POA with authority under Form 2848 3. Contact Person: The valid Form 2848 or Form 8821 holder will be contacted for additional information if necessary. If utilizing Form 8821 please identify all individuals covered by the Form 8821 a. Name b. Firm c. Address d. Voice phone number e. Fax phone number Catalog Number 50991Q www.irs.gov Form 13930 (Rev. 6-2018) D-199http://www.irs.gov