Form 4669                                                 Department of the Treasury — Internal Revenue Service
(Rev. January 1993)                                       Statement of Payments Received
1.  Name and Address of Payee                                                                               2.  Social Security Number

3.  Name and Address of Payor                                                              4.  Calendar Year

                                                                                           5. Amount of Payments (Including Commissions,
                                                                                             Bonuses, Prizes, etc.) on Which Income Tax and
                                                                                             Social Security Tax Were Not Withheld
                                                                                             $
The above Payments on which there was no withholding of federal income or social security tax, were reported on my tax return described
below.  The taxes due on that return have been paid in full.
6.  Name and Address Shown on Return                                                                        7. Spouse’s Social Security Number
                                                                                                            if a Joint Return was Filed

8.  Return Form Number                                      9.  Service Center Where Filed

10.  The Payments Shown in Item 5, Above, Are Reported On:
   a.  Line, ___________, Page ___________, of my return     b.  Schedule ___________ of my return.  If reported on Schedule C, F, or SE,
                                                                 Self-Employment       Tax of
                                                                   $_________________________ was paid.
Under penalties of perjury, I declare that to the best of my knowledge and belief the above information is true, correct, and complete.
11.  Signature of Payee                                                                                     12.  Date

                                     For Privacy Act Notice, see back of form.

Form 4669 (Rev. 1-93)                Catalog Number 41877Z        Department of the Treasury — Internal Revenue Service

                                                                 Privacy Act Notice

Under the Privacy Act of 1974 we must tell you:                                  We ask for tax return information to carry out the Internal Revenue laws
                                                                                 of the United States.  We need it to figure and collect the right amount of tax.
n Our legal right to ask for the information and whether
  the law says you must give it.
                                                                                 We may give the information to the Department of Justice and to other
n What major purposes we have in asking for it, and how                          Federal agencies, as provided by law.  We may also give it to cities, states,
  it will be used.                                                               the District of Columbia, and U.S. commonwealths or possessions to carry
                                                                                 out their tax laws.  And we may give it to foreign governments because of tax
n What could happen if we do not receive it.                                     treaties they have with the United States.

  The law covers:                                                                If you do not file a return, do not provide the information we ask for, or
                                                                                 provide fraudulent information, the law provides that you may be charged
n Tax returns and any papers filed with them.                                    penalties and, in certain cases, you may be subject to criminal prosecution.
                                                                                 We may also have to disallow the exemptions, exclusions, credits, deduc-
n Any questions we need to ask you so we can:                                    tions, or adjustments shown on the tax return.  This could make the tax
                                                                                 higher or delay any refund.  Interest may also be charged.
  Complete, correct, or process your return.
  Figure your tax.
  Collect tax, interest, or penalties.                                           Please keep this notice with your records.  It may help you if we ask you
                                                                                 for other information.
  Our legal right to ask for information is Internal Revenue Code sections
6001, 6011, and 6012(a), and their regulations.  They say that you must file
a return or statement with us for any tax you are liable for.  Code section 6109 If you have questions about the rules for filing and giving information,
and its regulations say that you must show your social security number on        please call or visit any Internal Revenue Service office.
what you file.  This is so we know who you are, and can process your return
and papers.
                                                                                 This is the only notice we must give you to explain the Privacy Act.
  You must fill in all parts of the tax form that apply to you.  But you do not  However, we may give you other notices if we have to examine your return
have to check boxes for the Presidential Election Campaign Fund.                 or collect any tax, interest, or penalties.