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Trustee:
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Trustee/Issuer's Federal Identification Number (FIN):
00-7412733 |
SAMPLE PAYER 1 | |
5071 NINTH AVE | |
NEW ORLEANS, LA 70032 | |
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Participant:
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Participant's Identification Number:
503-00-1959 |
CHRIS JOHNSON | |
1990 FOURTH ST | |
TAMPA, FL 33607 | |
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Submission Type: | Original document |
Account Number (Optional): | 999999999 |
IRA Contributions: | $100.00 |
Rollover Contributions: | $0.00 |
Roth Conversion Amount: | $0.00 |
Recharacterized Contributions: | $0.00 |
Fair Market Value of Account: | $101.00 |
Life Insurance Cost Included in Box 1: | $0.00 |
SEP Code: | Not Checked |
IRA Code: | Checked |
Simple Code: | Not Checked |
Roth IRA Code: | Not Checked |
RMD For Subsequent Year: | RMD box not checked |
RMD Date: | 00-00-0000 |
Year: | |
Postponed Contribution Code: | |
Repayments Code: | |
Fair Market Value of certain specified assets: | N/A |
SEP Contributions: | $0.00 |
SIMPLE Contributions: | $0.00 |
Roth IRA Contributions: | $0.00 |
Required Minimum Distribution Amount: | $0.00 |
Postponed Contributions: | $0.00 |
Repayment of a qualified reservist distribution or federally designated disaster withdrawal repayment: | $0.00 |
Fair Market Value of Certain Specified Assets: | $0.00 |
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Payer:
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Payer's Federal Identification Number (FIN):
00-7758501 |
SAMPLE PAYER 2 | |
9254 FIFTH ST | |
DETROIT, MI 48216 | |
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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 |