| |
Creditor:
| |
Creditor's Federal Identification Number (FIN):
00-5888357 |
SAMPLE PAYER 1 | |
7537 LAKE AVE | |
KANSAS CITY, MO 64112 | |
| |
Debtor:
| |
Debtor's Identification Number:
503-00-1959 |
CHRIS JOHNSON | |
1990 FOURTH ST | |
TAMPA, FL 33607 | |
| |
Submission Type: | Original document |
Account Number (Optional): | 999999999 |
Date Canceled: | 12-31-2018 |
Property Fair Market Value: | $0.00 |
Amount of Debt Discharged: | $8,348.00 |
Interest Forgiven Amount: | $0.00 |
Identifiable Event Code: | Creditor's debt collection Policy |
Debt Description: | DDA EXPENDITURE |
Personal Liability Indicator: | Box checked-Personally Liable |
| |
Creditor:
| |
Creditor's Federal Identification Number (FIN):
00-4625582 |
SAMPLE PAYER 2 | |
6252 OAK ST | |
AKRON, OH 44223 | |
| |
Debtor:
| |
Debtor's Identification Number:
503-00-1959 |
CHRIS JOHNSON | |
1990 FOURTH ST | |
TAMPA, FL 33607 | |
| |
Submission Type: | Original document |
Account Number (Optional): | 999999999 |
Date Canceled: | 12-31-2018 |
Property Fair Market Value: | $0.00 |
Amount of Debt Discharged: | $7,940.00 |
Interest Forgiven Amount: | $0.00 |
Identifiable Event Code: | Creditor's debt collection Policy |
Debt Description: | DDA EXPENDITURE |
Personal Liability Indicator: | Box checked-Personally Liable |
| |
Payer:
| |
Payer's Federal Identification Number (FIN):
00-4664014 |
SAMPLE PAYER 3 | |
6015 ELM AVE | |
DETROIT, MI 48216 | |
| |
Recipient:
| |
Recipient's Identification Number:
503-00-1959 |
CHRIS JOHNSON | |
1990 FOURTH ST | |
TAMPA, FL 33607 | |
| |
Submission Type: | Original document |
Account Number (Optional): | 999999999 |
Interest: | $4.00 |
Tax Withheld: | $0.00 |
Savings Bonds: | $0.00 |
Investment Expense: | $0.00 |
Interest Forfeiture: | $0.00 |
Foreign Tax Paid: | $0.00 |
Tax-Exempt Interest: | $0.00 |
Specified Private Activity Bond Interest: | $0.00 |
Market Discount: | $0.00 |
Bond Premium: | $0.00 |
Bond Premium on Tax Exempt Bond: | $0.00 |
Bond Premium on Treasury Obligations: | $0.00 |
Second Notice Indicator: | No Second Notice |
Foreign Country or US Possession: | |
CUSIP Number: | |
FATCA Filing Requirement: | Box not checked no Filing Requirement |
| |
Payer:
| |
Payer's Federal Identification Number (FIN):
00-2875258 |
SAMPLE PAYER 4 | |
9885 CEDAR ST | |
ATLANTA, GA 30305 | |
| |
Recipient:
| |
Recipient's Identification Number:
503-00-1959 |
CHRIS JOHNSON | |
1990 FOURTH ST | |
TAMPA, FL 33607 | |
| |
Submission Type: | Original document |
Account Number (Optional): | 999999999 |
Interest: | $4.00 |
Tax Withheld: | $0.00 |
Savings Bonds: | $0.00 |
Investment Expense: | $0.00 |
Interest Forfeiture: | $0.00 |
Foreign Tax Paid: | $0.00 |
Tax-Exempt Interest: | $0.00 |
Specified Private Activity Bond Interest: | $0.00 |
Market Discount: | $0.00 |
Bond Premium: | $0.00 |
Bond Premium on Tax Exempt Bond: | $0.00 |
Bond Premium on Treasury Obligations: | $0.00 |
Second Notice Indicator: | No Second Notice |
Foreign Country or US Possession: | |
CUSIP Number: | |
FATCA Filing Requirement: | Box not checked no Filing Requirement |
| |
Payer:
| |
Payer's Federal Identification Number (FIN):
00-8298575 |
SAMPLE PAYER 5 | |
9885 MAPLE AVE | |
DETROIT, MI 48216 | |
| |
Recipient:
| |
Recipient's Identification Number:
503-00-1959 |
CHRIS JOHNSON | |
1990 FOURTH ST | |
TAMPA, FL 33607 | |
| |
Submission Type: | Original document |
Account Number (Optional): | 999999999 |
Interest: | $4.00 |
Tax Withheld: | $0.00 |
Savings Bonds: | $0.00 |
Investment Expense: | $0.00 |
Interest Forfeiture: | $0.00 |
Foreign Tax Paid: | $0.00 |
Tax-Exempt Interest: | $0.00 |
Specified Private Activity Bond Interest: | $0.00 |
Market Discount: | $0.00 |
Bond Premium: | $0.00 |
Bond Premium on Tax Exempt Bond: | $0.00 |
Bond Premium on Treasury Obligations: | $0.00 |
Second Notice Indicator: | No Second Notice |
Foreign Country or US Possession: | |
CUSIP Number: | |
FATCA Filing Requirement: | Box not checked no Filing Requirement |
| |
Payer:
| |
Payer's Federal Identification Number (FIN):
00-8062958 |
SAMPLE PAYER 6 | |
2518 VIEW ST | |
PHOENIX, AZ 85005 | |
| |
Recipient:
| |
Recipient's Identification Number:
503-00-1959 |
CHRIS JOHNSON | |
1990 FOURTH ST | |
TAMPA, FL 33607 | |
| |
Submission Type: | Original document |
Account Number (Optional): | 999999999 |
Interest: | $0.00 |
Tax Withheld: | $0.00 |
Savings Bonds: | $0.00 |
Investment Expense: | $0.00 |
Interest Forfeiture: | $0.00 |
Foreign Tax Paid: | $0.00 |
Tax-Exempt Interest: | $0.00 |
Specified Private Activity Bond Interest: | $0.00 |
Market Discount: | $0.00 |
Bond Premium: | $0.00 |
Bond Premium on Tax Exempt Bond: | $0.00 |
Bond Premium on Treasury Obligations: | $0.00 |
Second Notice Indicator: | No Second Notice |
Foreign Country or US Possession: | |
CUSIP Number: | |
FATCA Filing Requirement: | Box not checked no Filing Requirement |