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Hidden Value Fields

Full Address

lfullAddress1

lfullAddress2

bfullAddress1

bfullAddress2

Country

lcountry

lcountry_nonUS

lcountry_US

bcountry

bcountry_nonUS

bcountry_US

bcountry1

bcountry1_nonUS

bcountry1_US

Dates

year

date13_pdf

General Information

Tax Year

Payer's Information

Payer's Name

Payer's TIN

Payer's Phone Number

Payer's Address

Country

Address (Number and Street)

Table
Apt/Ste No.	City
State Required No choices to choose from	Zip Code

Recipient’s Information

Recipient’s Name

Recipient’s TIN

Recipient’s Address

Country

Address (Number and Street)

Table
Apt/Ste No.	City
State Required No choices to choose from	Zip Code

Original Issue Discount

Account Number

2nd TIN not.

FATCA Filing Requirement

1. Original issue discount for the year

2. Other periodic interest

3. Early Withdrawal Penalty

4. Federal Income Tax Withheld

5. Market Discount

6. Acquisition Premium

7. Description

8. Original Issue Discount on U.S. Treasury Obligations

9. Investment Expenses

10. Bond Premium

11. Tax-Exempt OID

12a. State (Line 1)

13a. State Identification Number (Line 1)

14a. State Income Tax Withheld (Line 1)

Do you wish to enter a tax income withheld for a second state?

Yes

Email Information

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