3.24.8. Information Returns Processing

(1)

SC Block Control

ABC

<Enter>

The screen displays the ABC that was entered in the EOP dialog box, as described in IRM 3.24.37.2.5. It cannot be changed.

(2)

Block DLN

DLN

<Enter>

Enter the 11-digits as shown:

1. Form 1332 - from the Document Locator No.

2. Form 3893 - from box 2.

3. The KV EOP will verify the DLN from the first document of the block.

(3)

Batch Number

BATCH

<Enter>

Enter the batch number as follows:

1. Form 1332 - from the batch control number box.

2. Form 3893 - from box 3.

3. If not present, secure the number from the batch transmittal sheet.

(4)

Document Count

COUNT

<Enter>

Enter the document count as follows:

1. Form 1332 - the circled serial number. If a block (100 documents) or if a number is not circled enter 100.

2. Form 3893 - from box 4.

(5)

Credit Amount

CR

<Enter>

No entry required. Press <Enter> only.

(6)

Debit Amount

DB

<Enter>

No entry required. Press <Enter> only.

(7)

Tax Year Indicator

TRCODE

<Enter>

Enter the last two digits of the "tax year" as follows:

1. Form 1332 - two "edited digits" from the upper right corner.

2. Form 3893 - last two digits of the tax year from the first document in the block.

(8)

Account Type Code
Amend Doc Code
Count Code

IRPACC

<Enter>
★★★★★★

Enter the alpha-numeric digits from the "Trans. Code" box. Do not enter a hyphen (-) if present.

(9)

MFT

MFT

<Enter>

1. Enter the MFT 69 for Form 1096.

2. If not Form 1096, press <Enter> only.

(10)

Secondary Amount

SECAMT

<Enter>

No entry required. Press <Enter> only.

(11)

Source Code

SOURCE

<Enter>

If the control document is Form 3893, enter "4".

(12)

Year Digit

YEAR

<Enter>
★★★★★★

1. Enter the year digit as follows for all prior year (Form 1096) documents.

2. If the control document is a Form 3893, enter the digit from box 12 (current or otherwise) or written on the top.

(13)

Prior Year Prompt

PRIOR YEAR

<Enter>

Auto generates "0".

(14)

RPS

RPS

<Enter>

Enter this field as a blank for all IRP programs covered in this IRM. Enter a blank if misblocked, but under the right program.

(1)

Section Number

SECT:

<Enter>

Section "01" is always generated. No entry is required.

(2)

DLN Serial Number

SER#

<Enter>

Enter the last two digits of the 13-digit DLN from the upper portion of the form. If the serial number has been generated by the system (see IRM 3.24.37.4.5) verify that it matches the document being entered.

(3)

TIN of Payee (Payer for Form 1096)

TIN

<Enter>

Enter the nine-digit TIN

1. If not present press <Enter> only.

2. If less than nine-digits, enter the numeric digits shown followed by period(s).

3. If more than nine digits, enter the first eight numeric digits followed by a period.

4. Form 1096 - If both employee identification number (EIN) and social security number (SSN) are present, enter the EIN.

5. If two TINs of like type are present, enter periods.

6. For Form 1096 - If 9- (one nine is followed by a dash) , enter nine "9s".

7. Form W-2G - Enter from box 9, 11 or 12.

8. If illegible, enter periods.

(4)

Delete Indicator

DELE

<Enter>

Enter a "D" in this field and end the document whenever it is determined a document is misblocked or misplaced.

(5)

First Name Line

NAME1

<Enter>

Enter the full name(s) as shown or edited on the document. If present but illegible, enter a period (.) for the illegible characters. If blank enter a single period. DO NOT apply to Section 16 entries.

(6)

Second Name Line

NAME2

<Enter>

Enter the second name line as follows:

1. For in care of, enter the percent symbol (%), space and the name.

2. See special instructions in the narrative.

3. If present but illegible, enter a period (.) for the for illegible characters.

4. Use this field for a foreign street address.

5. See narrative portion of this IRM for foreign address procedures.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "02" always.

(2)

Street Address

ADDR

<Enter>

Enter the street address from the employee's, recipient's, or payer's (Form 1096) entity area.

1. If the address is illegible, missing, or coded "Z," enter a "Z" and press <Enter>.

2. Use this field for foreign city, state or province, and mailing code.

(3)

City

CITY

<Enter>

Enter the city from the appropriate entity area.

1. Use Major City Codes (MCC), if appropriate.

2. If the city is missing, illegible, or coded "ZZZ", enter "ZZZ" and press <Enter>.

(4)

State Code

ST

<Enter>

Enter the state code.

1. Press <Enter> only if a MCC is used.

2. If foreign address, use the first position of this field for the period (.).

(5)

ZIP Code

ZIP

<Enter>

Enter the ZIP Code.

(6)

Payee Account number

PACCT#

<Enter>

Enter the alpha-numeric digits from the account number box. Omit any special characters.

(7)

2nd TIN Notification

2NDTIN

<Enter>

1. If a circled "U" is coded to the right of the name on Name Line 1, enter "U" in the 2nd TIN Notification field Section 02.

2. Enter a "1" if the 2nd TIN Notification box is checked at the bottom of the form; otherwise, leave blank.

(8)

Amended Document Code

ADC

<Enter>

Enter a "G" if the "Corrected" box is checked or marked.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06" always.

(2)

Number of Original Documents

BOX3/

<Enter>
★★★★★★

1. Enter the count from box 3 only if a slash (/) has been edited.

2. Enter the count shown to the left of the slash.

(3)

Number of Amended Documents

/BOX3

<Enter>

1. Enter the count from box 3 only if a slash (/) has been edited.

2. Enter the count shown to the right of the slash.

(4)

Federal Income Tax Withheld

BOX4 $

<Enter>
★★★★★★

Enter the amount from box 4.

(5)

Total Amount Reported

BOX5 $

<Enter>
★★★★★★

Enter the amount from box 5.

(6)

TIN Type and Document Code

T/DC

<Enter>
★★★★★★

Enter the three digits identifying which document series was transmitted as follows:

1. TIN Type - Enter the edited "1" for an EIN or "2" for a SSN. If not edited determine the TIN Type.

2. Doc. Code - Enter the preprinted or edited doc. code from the checked box.

3. If less than three digits, enter the digits present and press <Enter> and alert your manager the forms are improperly coded.

4. If no box is marked in box 6, enter 95 as the doc code.

5. If multiple boxes are marked, use the document code of the first boxed marked.

(7)

Kind of Payments Reported Code

PC

<Enter>

Enter the edited alpha character from the area to the right of the bold words "INSTRUCTIONS," if present.

(8)

Delinquent Return Code

CODE

<Enter>

Enter the edited code shown in the first "For Official Use Only" box to right of the entity area.

(9)

Received Date

DATE

<Enter>

Enter the date in MMDDYY format as follows:

1. The edited or stamped received date shown above the six "For Official Use Only" boxes, OR

2. The edited received date shown in the "For Official Use Only" boxes to the right of the delinquent return code box.

3. Do not enter the date if either of the following conditions exist:

   1. There is no "X" coded in the first "For Official Use Only" box, OR

   2. Penalty has been assessed is written on the Form 1096.

4. For standard instructions, see IRM 3.24.37, ISRP System - General Instructions.

(10)

Correspondence Indicators

CORR

<Enter>

Enter the edited digits from the last two positions of the "For Official Use Only" boxes.

(11)

Number of Original Documents Subject to Penalty

BOT LF/

<Enter>

1. Enter the edited digits from the bottom left margin of the form.

2. If a slash (/) has been edited, enter only the count to the left of the slash.

(12)

Number of Amended Documents Subject to Penalty

/BOT LF

<Enter>

1. Enter the edited digits from the bottom left margin of the form.

2. If a slash (/) has been edited, enter only the count to the right of the slash.

(13)

Year Indicator

BOT RT

<Enter>

1. Enter the edited year digits (YY) from the bottom right margin. The century digits will generate.

2. If prior year documents are not edited, enter the year digits of the documents if noticed.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06" always.

(2)

Total

BOX1 $

<Enter>
★★★★★★

Enter the amount from box 1.

(3)

Code

BOX2A

<Enter>

Enter the code present in box 2a.

(4)

Unique identifier

BOX2B

<Enter>

Enter the ID from box 2b.

(5)

Bond type code

BOX3

<Enter>

Enter the three-digits from box 3.

(6)

January

BOX5A $

<Enter>
★★★★★★

Enter the amount from box 5a.

(7)

February

BOX5B $

<Enter>
★★★★★★

Enter the amount from box 5b.

(8)

March

BOX5C $

<Enter>
★★★★★★

Enter the amount from box 5c.

(9)

April

BOX5D $

<Enter>
★★★★★★

Enter the amount from box 5d.

(10)

May

BOX5E $

<Enter>
★★★★★★

Enter the amount from box 5e.

(11)

June

BOX5F $

<Enter>
★★★★★★

Enter the amount from box 5f.

(12)

July

BOX5G $

<Enter>
★★★★★★

Enter the amount from box 5g.

(13)

August

BOX5H $

<Enter>
★★★★★★

Enter the amount from box 5h.

(14)

September

BOX5I $

<Enter>
★★★★★★

Enter the amount from box 5i.

(15)

October

BOX5J $

<Enter>
★★★★★★

Enter the amount from box 5j.

(16)

November

BOX5K $

<Enter>
★★★★★★

Enter the amount from box 5k.

(17)

December

BOX5L $

<Enter>
★★★★★★

Enter the amount from box 5l.

(18)

1097-BTC issuer checkbox

5LFCKBX

<Enter>
★★★★★★

Enter "1" if the first check box is marked.
Enter "2" if the second box is marked.
Enter "3" if both boxes are marked.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06" always.

(2)

Mortgage interest

BOX1 $

<Enter>
★★★★★★

Enter the amount from box 1.

(3)

Outstanding mortgage principal

BOX2 $

<Enter>
★★★★★★

Enter the amount from box 2.

(4)

Mortgage origination date

BOX3

<Enter>

Enter the date from box 3 in MMDDYY format.

(5)

Refund of overpaid interest

BOX4 $

<Enter>
★★★★★★

Enter the amount from box 4.

(6)

Mortgage insurance premium

BOX5 $

<Enter>
★★★★★★

Enter the amount from box 5.

(7)

Points paid on purchase of principal residence

BOX6 $

<Enter>
★★★★★★

Enter the amount from box 6.

(8)

Address of property verification checkbox

BOX7

<Enter>

Enter "1" if box 7 is marked. Press <Enter> if box is not marked.

(9)

Address of property securing mortgage

BOX8

<Enter>

Enter information if present.

(10)

Number of mortgaged properties

BOX9

<Enter>
★★★★★★

Enter the information from box 9.

(11)

Other

BOX10

<Enter>

Enter the information if present.

(12)

Mortgage acquisition date

BOX11

<Enter>

Enter the date from box 11 in MMDDYY format.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06" always.

(2)

Date of contribution

BOX1

<Enter>

Enter the date from box 1, in the MMDDYY format.

(3)

Year

BOX2A

<Enter>

Enter the information from box 2b, in YYYY format.

(4)

Make

BOX2B

<Enter>

Enter alpha characters from box 2c. Do not enter numeric or special characters.

(5)

Model

BOX2C

<Enter>

Enter the alpha numeric information from box 2d. Do not enter special characters.

(6)

Vehicle or other identification number

BOX3

<Enter>

Enter the information from box 3.

(7)

Vehicle sold at arms length checkbox

4ACKBX

<Enter>

Enter a "1" if box 4a is checked. Press <Enter> if box is not marked.

(8)

Date of sale

BOX4B

<Enter>

Enter the date from box 4b, in the MMDDYY format.

(9)

Gross proceeds from sale

BOX4C $

<Enter>
★★★★★★

Enter the amount from box 4c.

(10)

Vehicle will not be transferred checkbox

5ACKBX

<Enter>

Enter a "1" if box 5a is checked. Press <Enter> if box is not marked.

(11)

Donee certifies needy individual

5BCKBX

<Enter>

Enter a "1" if box 5b is checked. Press <Enter> if box is not marked.

(12)

Description of material improvements

BOX5C

<Enter>

Enter the description from box 5c up to 39 alpha, numeric and special characters. Abbreviate, if possible, to enter as much data as possible.

(13)

Did you provide goods or services

6ACKBX

<Enter>

Enter a

1. "1" if box 6a is checked yes.

2. Enter a "2" if box 6a is checked no.

3. Press <Enter> if boxes are not marked.

(14)

Value of goods provided

BOX6B $

<Enter>
★★★★★★

Enter the amount from box 6b.

(15)

Description of goods and services

BOX6C

<Enter>

Enter the description from box 6c up to 39 alpha, numeric and special characters. Abbreviate, if possible, to enter as much data as possible.

(16)

Intangible religious benefit

6CCKBX

<Enter>

Enter a "1" if box 6c is checked. Press <Enter> if box is not marked.

(17)

Under law cannot claim more than $500

7CKBX

<Enter>

Enter a "1" if box 7 is checked. Press <Enter> if box is not marked.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06" always.

(2)

Student loan interest received by lender

BOX1 $

<Enter>
★★★★★★

Enter the amount from box 1.

(3)

Check if box 1 does not include loan origination fees

BOX2

<Enter>

Enter a "1" if box 2 is checked.
Press <Enter> if box is not marked.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06" always.

(2)

Total amount required to be paid

BOX1 $

<Enter>
★★★★★★

Enter the amount from box 1.

(3)

Amount to be paid for violation or potential violation

BOX2

<Enter>

Enter the amount from box 2.

(4)

Restitution/remediation amount

BOX3 $

<Enter>
★★★★★★

Enter the amount from box 3.

(5)

Compliance amount

BOX4$

<Enter>
★★★★★★

Enter the amount from box 4.

(6)

Date of order or agreement

BOX5

<Enter>

Enter the date from box 5, in the MMDDYY format.

(7)

Court or Entity

BOX6

<Enter>

Enter the description from box 6 up to 39 alpha, numeric and special characters.

(8)

Case number

BOX7

<Enter>

Enter the description from box 7 up to 39 alpha, numeric and special characters.

(9)

Name or description of matter/suit/agreement

BOX8

<Enter>

Enter the description from box 8 up to 39 alpha, numeric, and special characters. Abbreviate, if possible, to enter as much data as possible.

(10)

Code

BOX9

<Enter>

Enter the code present from box 9 up to five characters.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06" always.

(2)

Annuity amount on start date

BOX1A $

<Enter>
★★★★★★

Enter the amount from box 1a.

(3)

Annuity start date

BOX1B

<Enter>

Enter the date from box 1b in MMDDYY format.
The century will generate.

(4)

Start date may be accelerated checkbox

BOX2

<Enter>

Enter "1" if box is marked. Press <Enter> if box is not marked.

(5)

Total premiums

BOX3 $

<Enter>
★★★★★★

Enter the amount from box 3.

(6)

FMV of QLAC

BOX4 $

<Enter>
★★★★★★

Enter the amount from box 4.

(7)

January amount

BOX5A $

<Enter>
★★★★★★

Enter the amount from box 5a.

(8)

February amount

BOX5B $

<Enter>
★★★★★★

Enter the amount from box 5b.

(9)

March amount

BOX5C $

<Enter>
★★★★★★

Enter the amount from box 5c.

(10)

April amount

BOX5D $

<Enter>
★★★★★★

Enter the amount from box 5d.

(11)

May amount

BOX5E $

<Enter>
★★★★★★

Enter the amount from box 5e.

(12)

June amount

BOX5F $

<Enter>
★★★★★★

Enter the amount from box 5f.

(13)

July amount

BOX5G $

<Enter>
★★★★★★

Enter the amount from box 5g.

(14)

August amount

BOX5H $

<Enter>
★★★★★★

Enter the amount from box 5h.

(15)

September amount

BOX5I $

<Enter>
★★★★★★

Enter the amount from box 5i.

(16)

October amount

BOX5J $

<Enter>
★★★★★★

Enter the amount from box 5j.

(17)

November amount

BOX5K $

<Enter>
★★★★★★

Enter the amount from box 5k.

(18)

December amount

BOX5L $

<Enter>
★★★★★★

Enter the amount from box 5l.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06" always.

(2)

Qualified tuition and related expenses

BOX1 $

<Enter>
★★★★★★

Enter the amount from box 1.

(3)

Student’s TIN indicator

TINCKBX

<Enter>

Enter a "1" if box is marked. Press <Enter> if box is not marked.

(4)

Adjustments made for a prior year

BOX4 $

<Enter>
★★★★★★

Enter the amount from box 4.

(5)

Scholarships or grants

BOX5 $

<Enter>
★★★★★★

Enter the amount from box 5.

(6)

Adjustments to scholarships or grants for a prior year

BOX6 $

<Enter>
★★★★★★

Enter the amount from box 6.

(7)

Checkbox academic period Jan-Mar

BOX7

<Enter>

Enter a "1" if box 7 is checked. Press <Enter> if box is not marked.

(8)

Check if at least half-time student

BOX8

<Enter>

Enter a "1" if box 8 is checked. Press <Enter> if box is not marked.

(9)

Check if a graduate student

BOX9

<Enter>

Enter a "1" if box 9 is checked. Press <Enter> if box is not marked.

(10)

Ins. reimb./refund

BOX10 $

<Enter>
★★★★★★

Enter the amount from box 10.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06" always.

(2)

Balance of principal outstanding

BOX2 $

<Enter>
★★★★★★

Enter the amount from box 2.

(3)

Fair market value of property

BOX4 $

<Enter>
★★★★★★

Enter the amount from box 4.

(4)

Check here if the borrower was personally liable >

BOX5

<Enter>

Enter "1" if box 5 is checked. Press <Enter> if box is not checked.

(5)

Description of property

BOX6

<Enter>

Enter the description from box 6 up to 39 alpha, numeric and special characters. Abbreviate, if possible, to enter as much data as possible.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06" always.

(2)

Description of property

BOX1A

<Enter>

Enter the description from box 1a up to 39 alpha, numeric and special characters. Abbreviate if possible, to enter as much data as possible.

(3)

Date acquired

BOX1B

<Enter>

Enter the date from box 1b, in MMDDYY format.

(4)

Date sold or disposed

BOX1C

<Enter>

Enter the date from box 1c, in MMDDYY format.

(5)

Proceeds

BOX1D $

<Enter>
MINUS (-)
★★★★★★

Enter the amount from box 1d.

(6)

Cost or other basis

BOX1E $

<Enter>
★★★★★★

Enter the amount from box 1e.

(7)

Accrued market discount

BOX1F $

<Enter>
★★★★★★

Enter the amount from box 1f.

(8)

Wash sale disallowed

BOX1G $

<Enter>
MINUS (-)
★★★★★★

Enter the amount from box 1g.

(9)

Type of gain or loss

2CKBX

<Enter>

Enter the checked boxes from box 2 as follows:

1. "1" if Short-term box is checked.

2. "2" if Long-term box is checked.

3. "3" if Ordinary and Short-Term boxes are checked.

4. “4” if Ordinary and Long-Term boxes are checked.

5. Press <Enter> if there are no boxes checked or if only the Ordinary box is checked.

(10)

Check if proceeds from

3CKBX

<Enter>

Enter the checked boxes from box 3 as follows:

1. "1" if the Collectibles box is checked.

2. "2" if the QOF box is checked.

3. "3" if both boxes are checked.

4. If no boxes are checked, press <Enter>.

(11)

Federal income tax withheld

BOX4 $

<Enter>
★★★★★★

Enter the amount from box 4.

(12)

Check if noncovered security

5CKBX

<Enter>

Enter "1" if box 5 is checked. Press <Enter> if box is not checked.

(13)

Report to IRS Gross/Net

6CKBX

<Enter>

Enter the checked boxes from box 6 as follows:

1. "1" if the Gross proceeds box is checked.

2. "2" if the Net proceeds box is checked.

3. "3" if both boxes are checked.

4. If no boxes are checked, press <Enter>.

(14)

Check if loss is not allowed based on amount in 1d

7CKBX

<Enter>

Enter "1" if box is checked. Press <Enter> if box is not marked.

(15)

Profit or (loss) realized in yyty on closed contracts

BOX8 $

<Enter> MINUS(-)
★★★★★★

Enter the amount from box 8.

(16)

Unrealized profit or (loss) on open contracts --12/31/yyty-1

BOX9 $

<Enter> MINUS(-)
★★★★★★

Enter the amount from box 9.

(17)

CUSIP number

CUSIP

<Enter>

Enter the CUSIP number found in the bottom left box.

(18)

FATCA checkbox

FATCACKBX

<Enter>

Enter a "1" if box is marked. Press <Enter> if box is not marked.

(19)

Unrealized profit or (loss) on open contracts --12/31/yyty

BOX10 $

<Enter> MINUS(-)
★★★★★★

Enter the amount from box 10.

(20)

Aggregate profit or (loss)

BOX11 $

<Enter> MINUS(-)
★★★★★★

Enter the amount from box 11.

(21)

Check if basis reported to IRS

12CKBX

<Enter>

Enter a "1" if marked. Press <Enter> if box is not marked.

(22)

Bartering

BOX13 $

<Enter>
★★★★★★

Enter the amount from box 13.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06"always.

(2)

Date of identifiable event

BOX1

<Enter>
★★★★★★

Enter the date from box 1, in the MMDDYY format.

(3)

Amount of debt discharged

BOX2 $

<Enter>
★★★★★★

Enter the amount from box 2.

(4)

Interest included in box 2

BOX3 $

<Enter>
★★★★★★

Enter the amount from box 3.

(5)

Debt description

BOX4

<Enter>

Enter the description from box 4 up to 39 alpha, numeric and special characters. Abbreviate, if possible, to enter as much data as possible.

(6)

Was debtor personally liable

BOX5

<Enter>

Enter a "1" if box 5 is checked. Press <Enter> if the box is not marked.

(7)

Identifiable event code

BOX6CD

<Enter>

Enter the code present in box 6.

(8)

Fair market value of property

BOX7 $

<Enter>
★★★★★★

Enter the amount from box 7.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06" always.

(2)

Date of sale or exchange

BOX1

<Enter>
★★★★★★

Enter the date from box 1, in MMDDYY format.

(3)

Aggregate amount rec’d

BOX2 $

<Enter>
★★★★★★

Enter the amount from box 2.

(4)

No. of shares exchanged

BOX3

<Enter>

Enter from box 3.

(5)

Classes of stock exchanged

BOX4

<Enter>

Enter from box 4.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06" always.

(2)

Total ordinary dividends

BOX1A $

<Enter>
★★★★★★

Enter the amount from box 1a.

(3)

Qualified dividends

BOX1B $

<Enter>
★★★★★★

Enter the amount from box 1b.

(4)

Total capital gain distr.

BOX2A $

<Enter>
MINUS (-)
★★★★★★

Enter the amount from box 2a.

(5)

Unrecap. Sec 1250 gain

BOX2B $

<Enter>
★★★★★★

Enter the amount from box 2b.

(6)

Section 1202 gain

BOX2C $

<Enter>
★★★★★★

Enter the amount from box 2c.

(7)

Collectible (28%) gain

BOX2D $

<Enter>
★★★★★★

Enter the amount from box 2d.

(8)

Section 897 Ordinary dividens

BOX2E $

<Enter>
★★★★★★

Enter the amount from box 2e.

(9)

Section 897 Capital gain

BOX2F $

<Enter>
★★★★★★

Enter the amount from box 2f.

(10)

Nondividend distributions

BOX3 $

<Enter>
★★★★★★

Enter the amount from box 3.

(11)

Federal income tax withheld

BOX4 $

<Enter>
★★★★★★

Enter the amount from box 4.

(12)

Section 199A dividends

BOX5 $

<Enter>
★★★★★★

Enter the amount from box 5.

(13)

Investment expenses

BOX6 $

<Enter>
★★★★★★

Enter the amount from box 6.

(14)

Foreign tax paid

BOX7 $

<Enter>
★★★★★★

Enter the amount from box 7.

(15)

Cash liquidation distributions

BOX9 $

<Enter>
★★★★★★

Enter the amount from box 9.

(16)

Noncash liquidation distributions

BOX10 $

<Enter>
★★★★★★

Enter the amount from box 10.

(17)

FATCA checkbox

FATCACKBX

<Enter>

Enter a "1" if box is marked. Press <Enter> if box is not marked.

(18)

Exempt-interest dividends

BOX11 $

ENTER>
★★★★★★

Enter the amount from box 11.

(19)

Specified private activity dividends

BOX12 $

ENTER>
★★★★★★

Enter the amount from box 12.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06"always.

(2)

Unemployment compensation

BOX1 $

<Enter>
★★★★★★

Enter the amount from box 1.

(3)

State or local income tax, refunds, credits, or offsets

BOX2 $

<Enter>
★★★★★★

Enter the amount from box 2.

(4)

Box 2 amount is for tax year

BOX3

<Enter>

Enter the year from box 3 in YY format.

(5)

Federal income tax withheld

BOX4 $

<Enter>
★★★★★★

Enter the amount from box 4.

(6)

RTAA Payments

BOX5 $

<Enter>
★★★★★★

Enter the amount from box 5.

(7)

Taxable grants

BOX6 $

<Enter>
★★★★★★

Enter the amount from box 6.

(8)

Agricultural payments

BOX7 $

<Enter>
★★★★★★

Enter the amount from box 7.

(9)

Trade or business checkbox

BOX8

<Enter>

Enter a "1" if box 8 is checked.
Press <Enter> if the box is not marked.

(10)

Market gain

BOX9 $

<Enter>
★★★★★★

Enter the amount from box 9.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06" always.

(2)

Interest income

BOX1 $

<Enter>
★★★★★★

Enter the amount from box 1.

(3)

Early withdrawal penalty

BOX2 $

<Enter>
★★★★★★

Enter the amount from box 2.

(4)

Interest on U.S. Savings Bonds

BOX3 $

<Enter>
★★★★★★

Enter the amount from box 3.

(5)

Federal income tax withheld

BOX4 $

<Enter>
★★★★★★

Enter the amount from box 4.

(6)

Investment expenses

BOX5 $

<Enter>
★★★★★★

Enter the amount from box 5.

(7)

Foreign tax paid

BOX6 $

<Enter>
★★★★★★

Enter the amount from box 6.

(8)

Foreign country or U.S. possession

BOX7

<Enter>

Enter the information from box 7.

(9)

Tax-exempt interest

BOX8 $

<Enter>
★★★★★★

Enter the amount from box 8.

(10)

Specified private activity bond interest

BOX9 $

<Enter>
★★★★★★

Enter the amount from box 9.

(11)

Market discount

BOX10 $

<Enter>
★★★★★★

Enter the amount from box 10.

(12)

Bond premium

BOX11 $

<Enter>
★★★★★★

Enter the amount from box 11.

(13)

FATCA checkbox

FATCACKBX

<Enter>

Enter a "1" if box is marked. Press <Enter> if box is not marked.

(14)

Bond premium on Treasury obligations

BOX12 $

<Enter>
★★★★★★

Enter the amount from box 12.

(15)

Bond premium on tax-exempt bond

BOX13 $

<Enter>
★★★★★★

Enter the amount from box 13.

(16)

Tax-exempt and tax credit bond CUSIP no.

BOX14

<Enter>

Enter the alpha/numeric information from box 14.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise, enter "06" always.

(2)

(PSE) or (EPF) checkbox

PSE/EPF

<Enter>

Enter a

1. "1" if the "PSE" box is checked,

2. "2" if the "EPF" box is checked.

(3)

Payment Card/Third party network checkbox

PAY/3RD

<Enter>

Enter a

1. "1" if the Payment Card box is checked,

2. "2" if the Third-party network box is checked.

(4)

Gross payment card/third party payments

BOX1A $

<Enter>
MINUS (-)
★★★★★★

Enter the amount from box 1a.

(5)

Card Not Present transactions

BOX1B $

<Enter>
★★★★★★

Enter the amount from box 1b.

(6)

Merchant category code

BOX2

<Enter>

1. Enter the four-digit code in box 2.

2. If only three digits are present, add a "0" as the first digit. If less than three digits or alpha characters are present, press <Enter>.

(7)

Number of payment transactions

BOX3

<Enter>

Enter the number in box 3.

(8)

Federal income tax withheld

BOX4 $

<Enter>
★★★★★★

Enter the amount from box 4.

(9)

January

BOX5A $

<Enter>
★★★★★★

Enter the amount from box 5a.

(10)

February

BOX5B $

<Enter>
★★★★★★

Enter the amount from box 5b.

(11)

March

BOX5C $

<Enter>
★★★★★★

Enter the amount from box 5c.

(12)

April

BOX5D $

<Enter>
★★★★★★

Enter the amount from box 5d.

(13)

May

BOX5E $

<Enter>
★★★★★★

Enter the amount from box 5e.

(14)

June

BOX5F $

<Enter>
★★★★★★

Enter the amount from box 5f.

(15)

July

BOX5G $

<Enter>
★★★★★★

Enter the amount from box 5g.

(16)

August

BOX5H $

<Enter>
★★★★★★

Enter the amount from box 5h.

(17)

September

BOX5I $

<Enter>
★★★★★★

Enter the amount from box 5i.

(18)

October

BOX5J $

<Enter>
★★★★★★

Enter the amount from box 5j.

(19)

November

BOX5K $

<Enter>
★★★★★★

Enter the amount from box 5k.

(20)

December

BOX5L $

<Enter>
★★★★★★

Enter the amount from box 5l.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise, enter "06" always.

(2)

Amount paid to payment recipient

BOX1 $

<Enter>
★★★★★★

Enter the amount from box 1.

(3)

Date of sale

BOX2

<Enter>
★★★★★★

Enter the date from box 2, in MMDDYY format.

(4)

Issuer’s name

INAME

<Enter>

Enter the contact’s name if present up to 39 alpha, numeric and special characters. Abbreviate, if possible, to enter as much data as possible.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise, enter "06" always.

(2)

Gross long-term care benefits paid

BOX1 $

<Enter>
★★★★★★

Enter the amount from box 1.

(3)

Accelerated death benefits paid

BOX2 $

<Enter>
★★★★★★

Enter the amount from box 2.

(4)

Check one

BOX3

<Enter>

Enter the boxes checked from box 3 as follows:

1. "1" if first box Per Diem is checked.

2. "2" if the second box Reimbursed is checked.

3. "3" if both boxes are checked.

4. Press <Enter> if no boxes are marked.

(5)

Insured's TIN

ITIN

<Enter>

Enter the TIN from the Insured's TIN box.

(6)

Insured's name

INAME

<Enter>

Enter the Insured’s name.

(7)

Chronically ill/Terminally ill checkboxes

BOX5

<Enter>

Enter the boxes checked from box 5 as follows:

1. "1" if first box Chronically is checked.

2. "2" if the second box Terminally is checked.

3. "3" if both boxes are checked.

4. Press <Enter> if no boxes are marked.

(8)

Date certified

DATE

<Enter>

Enter the date in MMDDYY format, from the Date certified box.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06"always.

(2)

Rents

BOX1 $

<Enter>
★★★★★★

Enter the amount from box 1.

(3)

Royalties

BOX2 $

<Enter>
★★★★★★

Enter the amount from box 2.

(4)

Other income

BOX3 $

<Enter>
★★★★★★

Enter the amount from box 3.

(5)

Federal income tax withheld

BOX4 $

<Enter>
★★★★★★

Enter the amount from box 4.

(6)

Fishing boat proceeds

BOX5 $

<Enter>
★★★★★★

Enter the amount from box 5.

(7)

Medical and health care payments

BOX6 $

<Enter>
★★★★★★

Enter the amount from box 6.

(8)

Direct sales indicator

BOX7

<Enter>

Enter a "1" if box 7 is marked. Press <Enter> if the box is not marked.

(9)

Substitute payments

BOX8 $

<Enter>
★★★★★★

Enter the amount from box 8.

(10)

Crop insurance proceeds

BOX9 $

<Enter>
★★★★★★

Enter the amount from box 9.

(11)

Gross proceeds paid to an attorney

BOX10 $

<Enter>
★★★★★★

Enter the amount from box 10.

(12)

Fish purchased for resale

BOX 11 $

<Enter>
★★★★★★

Enter the amount from box 11.

(13)

Section 409A deferrals

BOX12 $

<Enter>
★★★★★★

Enter the amount from box 12.

(14)

FATCA checkbox

FATCACKBX

<Enter>

Enter a "1" if box is marked. Press <Enter> if the box is not marked.

(15)

Excess golden parachute payments

BOX14 $

<Enter>
★★★★★★

Enter the amount from box 14.

(16)

Nonqualified deferred compensation

BOX15 $

<Enter>
★★★★★★

Enter the amount from box 15.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06" always.

(2)

Nonemployee compensation

BOX1 $

<Enter>
★★★★★★

Enter the amount from box 1.

(3)

Direct sales of $5,000 or more

BOX2 $

<Enter>
★★★★★★

Enter a "1" if box is marked. Press <Enter> if the box is not marked.

(4)

Federal income tax withheld

BOX4 $

<Enter>
★★★★★★

Enter the amount from box 4.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06" always.

(2)

Original issue discount for yyty

BOX1 $

<Enter>
★★★★★★

Enter the amount from box 1.

(3)

Other periodic interest

BOX2 $

<Enter>

Enter the amount from box 2.

(4)

Early withdrawal penalty

BOX3 $

<Enter>
★★★★★★

Enter the amount from box 3.

(5)

Federal income tax withheld

BOX4 $

<Enter>
★★★★★★

Enter the amount from box 4.

(6)

Market discount

BOX5 $

<Enter>
★★★★★★

Enter the amount from box 5.

(7)

Acquisition premium

BOX6 $

<Enter>
★★★★★★

Enter the amount from box 6.

(8)

Description

BOX7

<Enter>

Enter the description from box 7 up to 39 alpha, numeric and special characters. Abbreviate, if possible, to enter as much data as possible.

(9)

Original issue discount

BOX8 $

<Enter>
★★★★★★

Enter the amount from box 8.

(10)

FATCA checkbox

FATCACKBX

<Enter>

Enter a "1" if box is marked. Press <Enter> if box is not marked.

(11)

Investment expenses

BOX9 $

<Enter>
★★★★★★

Enter the amount from box 9.

(12)

Bond premium

BOX10 $

<Enter>
MINUS (-)
★★★★★★

Enter the amount from box 10.

(13)

Tax exempt OID

BOX11 $

<Enter>
★★★★★★

Enter the amount from box 11.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06" always.

(2)

Patronage dividends

BOX1 $

<Enter>
★★★★★★

Enter the amount from box 1.

(3)

Nonpatronage dividends

BOX2 $

<Enter>
★★★★★★

Enter the amount from box 2.

(4)

Per-unit retain allocations

BOX3 $

<Enter>
★★★★★★

Enter the amount from box 3.

(5)

Federal income tax withheld

BOX4 $

<Enter>
★★★★★★

Enter the amount from box 4.

(6)

Redeemed nonqualified notices

BOX5 $

<Enter>
★★★★★★

Enter the amount from box 5.

(7)

Section 199A(g) deduction

BOX6 $

<Enter>
★★★★★★

Enter the amount from box 6.

(8)

Qualified payments (Sec. 199A(b)(7))

BOX7 $

<Enter>
★★★★★★

Enter the amount from box 7.

(9)

Section 199A(a) qual. items

BOX8 $

<Enter>
★★★★★★

Enter the amount from box 8.

(10)

Section 199A(a) SSTB items

BOX9 $

<Enter>
★★★★★★

Enter the amount from box 9.

(11)

Investment credit

BOX10 $

<Enter>
★★★★★★

Enter the amount from box 10.

(12)

Work opportunity credit

BOX11 $

<Enter>
★★★★★★

Enter the amount from box 11.

(13)

Other credits and deductions

BOX12 $

<Enter>
★★★★★★

Enter the amount from box 12.

(14)

Specified Coop

13CKBX

<Enter>

Enter a "1" if box 13 is checked. Press <Enter> if box is not marked.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06" always.

(2)

Gross distribution

BOX1 $

<Enter>
★★★★★★

Enter the amount from box 1.

(3)

Earnings

BOX2 $

<Enter>
★★★★★★

Enter the amount from box 2.

(4)

Basis

BOX3 $

<Enter>
★★★★★★

Enter the amount from box 3.

(5)

Trustee-to-trustee transfer

BOX4

<Enter>

Enter a "1" if box 4 is checked. Press <Enter> if box is not marked.

(6)

Private, State, or Coverdell ESA

BOX5

<Enter>

Enter the boxes checked from box 5 as follows:

1. "1" if first box, Private is checked.

2. "2" if second box, State is checked.

3. "3" if third box "Coverdell ESA" is checked.

4. Press <Enter> if no boxes are marked.

(7)

Not designated beneficiary

BOX6

<Enter>

Enter a "1" if box 6 is checked. Press <Enter> if box is not marked.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06" always.

(2)

Gross distribution

BOX1 $

<Enter>
★★★★★★

Enter the amount from box 1.

(3)

Taxable amount

BOX2A $

<Enter>
★★★★★★

Enter the amount from box 2a.

(4)

Taxable amount not determined/Total distribution boxes

2BBXS

<Enter>

Enter the boxes checked from box 2b as follows from line 2b:

1. "1" if first box is checked.

2. "2" if second box is checked.

3. "3" if both boxes are checked.

4. Press <Enter> if no boxes are marked.

(5)

Capital gain

BOX3 $

<Enter>
★★★★★★

Enter the amount from box 3.

(6)

Federal income tax withheld

BOX4 $

<Enter>
★★★★★★

Enter the amount from box 4.

(7)

Net unrealized appreciation

BOX6 $

<Enter>
★★★★★★

Enter the amount from box 6.

(8)

Distribution codes

BOX7

<Enter>

Enter the codes from box 7.

(9)

IRA/SEP/SIMPLE

IRA/

<Enter>

Enter a "1" if the IRA/SEP/SIMPLE box is checked. Press <Enter> if box is not marked.

(10)

Amount allocable to IRR within 5 years

BOX10 $

<Enter>
★★★★★★

Enter the amount from box 10.

(11)

1st year of desg. Roth contrib.

BOX11

<Enter>

Enter the year in YYYY format from box 11.

(12)

FATCA checkbox

FATCACKBX

<Enter>

Enter a "1" if box 12 is marked. Press <Enter> is box is not marked.

(13)

Date of payment

BOX13

<Enter>

Enter the date if present in MMDDYY format in box 13 after the account number. Press <Enter> if no date is present.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06" always.

(2)

Date of closing

BOX1

<Enter>

Enter the date from box 1 in MMDDYY format.

(3)

Gross proceeds

BOX2 $

<Enter>
★★★★★★

Enter the amount from box 2.

(4)

Address or legal description

BOX3

<Enter>

1. Enter the information from box 3. If an address is present, enter the entire address in a continuous basis, spacing as necessary.

   Example: 696 Tulip Road Flowerville VA 22204

2. Enter the description from box 3 up to 39 alpha, numeric and special characters. Abbreviate if possible, to enter as much data as possible.

(5)

Transfer indicator

BOX4

<Enter>

Enter a "1" if box 4 is checked. Press <Enter> if box is not marked.

(6)

Foreign indicator

BOX5

<Enter>

Enter a “1” if box 5 is checked. Press <Enter> if not marked.

(7)

Buyer’s part of real estate tax

BOX6 $

<Enter>
★★★★★★

Enter the amount from box 6.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06" always.

(2)

Gross distribution

BOX1 $

<Enter>
★★★★★★

Enter the amount from box 1.

(3)

Earnings on excess cont.

BOX2 $

<Enter>
★★★★★★

Enter the amount from box 2.

(4)

Distribution code

BOX3

<Enter>

Enter the digit from box 3.

(5)

FMV on date of death

BOX4 $

<Enter>
★★★★★★

Enter the amount from box 4.

(6)

HSA, Archer MSA or MA MSA checkboxes

BOX5

<Enter>

Enter the checked boxes from box 5 as follows:

1. "1" if HSA box is checked.

2. "2" if Archer MSA box is checked.

3. "3" if MA MSA box is checked.

4. If multiple boxes are checked press <Enter> only.

5. Press <Enter> if no boxes are marked.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise, enter "06" always.

(2)

Investment in contract

BOX1 $

<Enter>
★★★★★★

Enter the amount from box 1.

(3)

Surrender amount

BOX2 $

<Enter>
★★★★★★

Enter the amount from box 2.

(4)

Issuer’s contact name

INAME

<Enter>

Enter the contact’s name if present up to 39 alpha, numeric and special characters. Abbreviate, if possible, to enter as much data as possible.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06" always.

(2)

Date option granted

BOX1

<Enter>

Enter the date from box 1 in MMDDYY format.

(3)

Date option exercised

BOX2

<Enter>

Enter the date from box 2 in MMDDYY format.

(4)

Exercised price per share

BOX3 $

<Enter>
★★★★★★

Enter the amount from box 3.

(5)

Fair market value per share on exercise date

BOX4 $

<Enter>
★★★★★★

Enter the amount from box 4.

(6)

No. of shares transferred

BOX5

<Enter>

Enter the number from box 5.

(7)

If other than Transferor, name/address/TIN

BOX6

<Enter>

Enter the name, address, and TIN.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06" always.

(2)

Date option granted

BOX1

<Enter>

Enter the date from box 1 in MMDDYY format.

(3)

Date option exercised

BOX2

<Enter>

Enter the date from box 2 in MMDDYY format.

(4)

Fair market value per share on grant date

BOX3 $

<Enter>
★★★★★★

Enter the amount from box 3.

(5)

Fair market value per share on exercise date

BOX4 $

<Enter>
★★★★★★

Enter the amount from box 4.

(6)

Exercise price paid per share

BOX5 $

<Enter>
★★★★★★

Enter the amount from box 5.

(7)

No. of shares transferred

BOX6

<Enter>
★★★★★★

Enter the number from box 6.

(8)

Date legal title transferred

BOX7

<Enter>

Enter the date from box 7 in MMDDYY format.

(9)

Excise price per share determined as if the option was exercised on the date shown in box 1.

BOX8 $

<Enter>

Enter the amount from box 8.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06" always.

(2)

IRA contributions

BOX1 $

<Enter>
★★★★★★

Enter the amount from box 1.

(3)

Rollover contributions

BOX2 $

<Enter>
★★★★★★

Enter the amount from box 2.

(4)

Roth IRA conversion amount

BOX3 $

<Enter>
★★★★★★

Enter the amount from box 3.

(5)

Recharacterized contributions

BOX4 $

<Enter>
★★★★★★

Enter the amount from box 4.

(6)

FMV of account

BOX5 $

<Enter>
★★★★★★

Enter the amount from box 5.

(7)

Life insurance cost included in box 1

BOX6 $

<Enter>
★★★★★★

Enter the amount from box 6.

(8)

IRA/SEP/SIMPLE/Roth IRA checkboxes

BOX7

<Enter>

Enter the boxes checked from box 7 as follows:

1. "1" if the IRA box is checked.

2. "2" if the SEP box is checked.

3. "3" if the SIMPLE box is checked.

4. "4" if the Roth IRA box is checked.

5. If no boxes are checked press <Enter>.

(9)

SEP contributions

BOX8 $

<Enter>
★★★★★★

Enter the amount from box 8.

(10)

SIMPLE contributions

BOX9 $

<Enter>
★★★★★★

Enter the amount from box 9.

(11)

Roth IRA contributions

BOX10 $

<Enter>
★★★★★★

Enter the amount from box 10.

(12)

RMD checkbox

BOX11

<Enter>

Enter a "1" if box 11 is checked. Press <Enter> if box is not marked.

(13)

RMD date

BOX12A

<Enter>

Enter the date from box 12a in MMDDYY format.

(14)

RMD amount

BOX12B $

<Enter>
★★★★★★

Enter the amount from box 12b.

(15)

Postponed/late contrib.

BOX13A $

<Enter>
★★★★★★

Enter the amount from box 13a.

(16)

Year

BOX13B

<Enter>

Enter the year from box 13b in YY format.

(17)

Code

BOX13C

<Enter>

Enter the code from box 13c.

(18)

Repayments

BOX14A $

<Enter>
★★★★★★

Enter the amount from box 14a.

(19)

Code

BOX14B

<Enter>

Enter the code from box 14b.

(20)

FMV of certain specified assets

BOX15A $

<Enter>
★★★★★★

Enter the amount from box 15a.

(21)

Code(s)

BOX15B

<Enter>

Enter the code or codes from box 15b.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06" always.

(2)

Coverdell ESA contributions

BOX1 $

<Enter>
★★★★★★

Enter the amount from box 1.

(3)

Rollover contributions

BOX2 $

<Enter>
★★★★★★

Enter the amount from box 2.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06" always.

(2)

Employee MSA contributions

BOX1 $

<Enter>
★★★★★★

Enter the amount from box 1.

(3)

Total contributions

BOX2 $

<Enter>
★★★★★★

Enter the amount from box 2.

(4)

Total HSA or Archer MSA contributions

BOX3 $

<Enter>
★★★★★★

Enter the amount from box 3.

(5)

Rollover contributions

BOX4 $

<Enter>
★★★★★★

Enter the amount from box 4.

(6)

Fair market value

BOX5 $

<Enter>
★★★★★★

Enter the amount from box 5.

(7)

HSA, Archer MSA or MA MSA checkboxes

BOX6

<Enter>

Enter the checked boxes from box 6 as follows:

1. "1" if HSA box is checked.

2. "2" if Archer MSA box is checked.

3. "3" if MA MSA box is checked.

4. If multiple boxes are checked, press <Enter> only.

5. Press <Enter> if no boxes are marked.

(1)

Section Number

SECT

<Enter>

<Enter> if already present on the screen; otherwise enter "06" always.

(2)

Gross winnings

BOX1 $

<Enter>
★★★★★★

Enter the amount from box 1.

(3)

Date won

BOX2

<Enter>

Enter the date from box 2 in MMDDYY format.

(4)

Federal income tax withheld

BOX4 $

<Enter>
★★★★★★

Enter the amount from box 4.

(5)

Winnings from identical wages

BOX7 $

<Enter>
★★★★★★

Enter the amount from box 7.

(1)

Section Number

SECT

<Enter>

<Enter> if already present; otherwise enter "16" always.

(2)

Payer Name Line 1

Name 1

<Enter>

1. For only the form attached to any payer identifier, enter the Payer Name line 1 shown on the form.

2. If illegible or not present, press <Enter>.

(3)

Payer Name Line 2

Name 2

<Enter>

1. For only the form attached to any payer identifier, enter the Payer Name line 2 shown on the form.

2. If illegible or not present, press <Enter>.

(4)

Payer Street Address

ADDR

<Enter>

1. For only the form attached to any payer identifier, enter the Payer Street Address shown on the form.

2. If the address is illegible or missing or coded "Z", enter "Z" and press <Enter>.

3. If the address is foreign press <Enter>.

(5)

Payer City

CITY