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Payer:
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Payer's Federal Identification Number (FIN):
00-6164799 |
SAMPLE PAYER 2 | |
7355 NINTH AVE | |
ATLANTA, GA 30305 | |
| |
| |
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: | $284.00 |
Total Employee Contributions: | $0.00 |
Unrealized Appreciation: | $0.00 |
Other Income: | $0.00 |
Gross Distribution: | $14,878.00 |
Taxable Amount: | $14,878.00 |
Eligible Capital Gains: | $0.00 |
Amount to IRR: | $0.00 |