EFTA Document EFTA01479213

Sheet1 Payer Name Payer Address(1) Payer Address(2) Payer City Payer State Paye r Zip Code Payer EIN Payer TCC Recipient Name Address (1) Address (2) Addr ess (3) City State Zip Code Foreign Country Recipient TIN Customer Account Number 1099 Type Taxable Amount Box 3 (other Income) Federal Tax Withheld (Box 4) Nonemployee Compensa tion (Box 7) State Tax Witheld(Boxl6) State Income (Box 18) State of Domicile Memb ership Value Higest State Marginal Tax Rate State Income