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efta-efta01195154DOJ Data Set 9OtherSCHEDULE B
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DOJ Data Set 9
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efta-efta01195154
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SCHEDULE B
(Form 1040A or 1040)
OWMFMndtherMetlly
klt(trkal ROVONJO Stni0a
(99)
09 Information about Schedule B (Form 1040A or 1040) and its instructions is at „„,„„, ,et (
o te.
*Nome
flown on natan
Interest and Ordinary Dividends
Ile Attach to Form 1040A or 1040.
JOSHUA M.
Part I
Interest
BLACK
did
OMB No I ra45•0074
2013
/tOoVonert
Sationroa No
CO
GS
Note. If you
received a Form
1099INT.
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 sellergnanced 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 b.
JMB 2011 TRUST
GOLDMAN SACHS A/C
CHASE A/C
JMB 2011 TRUST (TRON TRUST)
SUBTOTAL FOR LINE 1
TAX-EXEMPT INTEREST
SEE STATEMENT 9
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, Nne 8a
PP.
Amount
464,629
1,375.
39
121,870
587,913
-1,375.
586,538
3
4
586,538
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 p.
COLUMBIA MANAGEMENT
GOLDMAN SACHS A/C#
MICROSOFT CORPORATION
GOLDMAN SACHS A/CF
6 Add the amounts on line 5. Enter the total here and on Form 1040A. or Form 1040. line 9a
Il•
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?
46
3,656
12.
12.
6
3,726.
Yes
No
X
X
LHA For Paperwork Reduction Act Notice, see your tax return Instructions.
7
Schedule B (Form 1040A or 1040) 2013
EFTA01195154
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