| |
Payer:
| |
Payer's Federal Identification Number (FIN):
00-3948722 |
SAMPLE PAYER 2 | |
8257 SEVENTH ST | |
CHICAGO, IL 60603 | |
| |
| |
Recipient:
| |
Recipient's Identification Number:
976-00-1879 |
BRIAN MARTIN | |
7967 MAPLE ST | |
KNOXVILLE, TN 37918 | |
| |
Submission Type: | Original document |
Account Number (Optional): | 999999999 |
Distribution Code Value: | Normal distribution |
Distribution Code: | 7 |
Distribution Code Value: | Not significant |
Distribution Code: | Blank |
Tax Amount Undetermined Code: | Not checked |
Total Distribution Code: | Not checked |
First Year Roth Contribution: | 0000 |
SEP Indicator: | IRA/SEP/SIMP box not checked |
FATCA Indicator: | not FATCA |
Date of Payment for Reportable Death Benefits under Section 6050Y: | 00-00-0000 |
Tax Withheld: | $320.00 |
Total Employee Contributions: | $0.00 |
Unrealized Appreciation: | $0.00 |
Other Income: | $0.00 |
Gross Distribution: | $15,058.00 |
Taxable Amount: | $15,058.00 |
Eligible Capital Gains: | $0.00 |
Amount to IRR: | $0.00 |