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+++++FC~RH SSA'":L099 .... oOCi. AL .:~I::.CUI~I.[Y BENE:F']:T ¢ ................
<br /> +P~RT OF YOUR ~ ....... olLCUf~.I.]Y ............ ¢'~
<br /> oOC.LAL, ~?': ...... BELNE. I".I,~o MAY BE: '~'AXABI.,E INCOME: FOR 1993,
<br /> +USE $ 4759,20 FROM I~)OX ~5 I~)I~I,,,OW W:['l')"l "'o
<br />
<br /> (oLJ:;, [IESCRIPTIO~ OF ~OUN'T I~ I~OX 4 BC.L, OU¢
<br />i:l ~X , NI~{T BE.~,[:.I~' ,l,r~ (BOX ~ NI.~Uo ~OX 4) ~:t'OR ].993-$ 4759
<br />
<br /> (L.:>la, [l"l,l.,.:> NUNI~EIR :IF' YOLJ NEEI] 'FO CON'r~C'r
<br />
<br />P A :1: I:) B Y C HI~: C K (:) R D :[ R E C 'F 0 I~{: P 0 ~ ]: 'F, .................................................................................................................................... $ 4 :]~ 20 , ).,
<br />
<br /> 099 I:)TE:: ',l ~'.~/'~ 11~73 SSN: ',541.--09.-,~5791 DOC: G67 UNI'T: CG PG ~ 002
<br /> I:);
<br />Mli!:I]:I:CARI!!: PIREM]:UMS PAIl) FOR YOLJ ......................................................................................................................................... $ 439,170
<br />WOI~KIE:RS CONPENSAT]:C)N OI:H:;'~;ET, ..................................................................................................................................................... $ 0,C, 0
<br />DUCTZ[ON~3 F'OR WOI~K OIR OTHER ADJUE~THENTS ................................................................................................. $ 0,00
<br />A ',l: II T 0 A N (:) 'T' H I~ I~ F'A fl :[: L Y N E M E~ E~ I~ ............................................................................................................................................. $ 0 . 00
<br />A]TORNEY (',','EES ANO S~B]: OFF'SET, ................................................................................................................................................ $ 0,00
<br />
<br />U B T ~ A C T:
<br />NON'TAXAI~LI~: F~AYMEN'T~; ...................................................................................................................................................................................... $ 0 , O0
<br /> OUNTS F:OR OTt,,tER F:AN:[I,..Y MENE~ERS PA:lO TO YOU ................................................................................... '.1~ 0,00
<br /> 'T 0 T A I... S U Ii) 'T R A C T I 0 N ~;,,, :1; 0.00
<br /> Ii~ENEF'IT~[; F:'OI~ :1,99[j~ (AMOUN'I" SHO~N IN IiIOX :~)----$ 47Z?,20
<br />· ~,++I:)I~:fi~CI~:[PT]:ON 01',:' AMOUNT :IJN I~)OX 4+++
<br />IJ;:CKS RETURNEI) "('0 SSA .......................................................................................................................................................................... $ 0,00
<br />0 ,. ,
<br />t) UCTIONS F'OR WORK OR OTI..IEiR A[)JUSTMENTS ..................................................................................... $ 0,00
<br />OTHI~i',R RE]:~AYMI?.N'I'S ............................................................................................................................................................................................... $ 0 , O0
<br /> BENE:F::):'I'S RI;:PAII'.) Ti:) S~i~A IN 1993 (AMOUNT SI,,tOWN '.tZN I?OX 4),,,$ 0,00
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