1. Payer's Information

Payer Name:*

Payer's Street Address:*

Payer's City:*

State:*

ZIP Code:*

Country:

Payer's TIN:*

Payer's Telephone No.:

2. Recipient's Information

Recipient's TIN:*

Recipient's Name:*

Street Address:*

Recipient's City:*

State:*

ZIP Code:*

Country:

Account Number:

2nd TIN not.

Nonemployee compensation (Box 1):*

Federal income tax withheld (Box 4):

Excess golden parachute payments (Box 3):

State Tax Withheld (Line 1):

State/Payer’s State No. (Line 1):

State Income (Line 1):

Payer made direct sales of $5,000 or more of consumer products to a buyer (recipient) for resale

Are any of the taxes withheld in a secondary state?

State Tax Withheld (Line 2):

State/Payer’s State No. (Line 2):

State Income (Line 2):

Email Address:*

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