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efta-efta01195153DOJ Data Set 9OtherSCHEDULE B
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DOJ Data Set 9
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SCHEDULE B
(Form 1040A or 1040)
Owattrimfldthermeury
Interrkal ROVONJO StvAC0 (99) Ill• Information about Schedule B (Form 1040A or 1040) and its instructions is at „„,„„,
°nuk e
Name
town on naturn
Interest and Ordinary Dividends
► Attach to Form 1040A or 1040.
BENJAMIN E. BLACK
Part I
Interest
4,
OMB No I ra45•O074
2013
/tOoVonert
Sationroa No
WA1 a.Gn:v
Note. If you
received a Form
1093INT.
Form 10990ID,
or substitute
statement from
a brokerage firm,
list the firm's
name as the
payer and enter
the total interest
shown on that
form.
1 List name of payer. If any interest is from a seller•financed mortgage and the buyer used the
property as a personal residence, see instructions and list this interest first. Also, show that
buyer's social security number and address BB.
BEB 2011 TRUST YGGDRASIL TRUST)
JPMORGAN A/C#
BEB 2011 TRUST (BENJAMIN BLACK 2010 TRUST)
FROM K-1 - FARMERSWEB LLC
2 Add the amounts on line 1
3 Excludable interest on series EE and I U.S. savings bonds issued after 1989.
Attach Form 8815
4 Subtract line 3 from line 2. Enter the result here and on Form 1040A, or Form 1040, line 8a
Amount
121,870
3
82,266
21
204,160
3
4
204,160
Note. If line 4 is over 51.500. you must complete Part III
Amount
Part II
Ordinary
Dividends
Note. If you
received a Form
1099DIV or
substitute
statement from
a brokerage firm.
list the firm's
name as the
payer and enter
the ordinary
dividends shown
on that form.
Part III
Foreign
Accounts
and
Trusts
321501
09-30-13
If "Yes,' you may have to file Form 3520. See instructions
5 List name of payer ►
JPMORGAN A/C#
THE WALT DISNEY COMPANY
6 Add the amounts on line 5. Enter the total here and on Form 1040A. or Form 1040. line 9a
Ie.
Note. If line 6 is over $1,500. you must complete Part III.
You must complete this part if you (a) had over $1,500 of taxable interest or ordinary dividends: (b) had a foreign
account: or (c) received a distribution from. or were a grantor of. or a transferor to. a foreign trust.
la At any time during 2013, did you have a financial interest in or signature authority over a financial account (such
as a bank account, securities account, or brokerage account) located in a foreign country? See instructions
If "Yes,' are you required to file FinCEN Form 114, Report of Foreign Bank and Financial Accounts (FBAR),
formerly TD F 90.22.1 to report that financial interest or signature authority? See FinCEN Form 114 and its
instructions for filing requirements and exceptions to those requirements
b If you are required to file FinCen Form 114, enter the name of the foreign country where the financial account
is located
►
8
During 2013, did you receive a distribution from, or were you the grantor of. or transferor to. a foreign trust?
1,915.
13
6
1,928.
Yes
No
X
X
LHA For Paperwork Reduction Act Notice, see your tax return Instructions.
7
Schedule B (Form 1040A or 1040) 2013
EFTA01195153
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