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ter the flier's name, address gnoluding room, suite, or other unit number), and TIN In the spaces provided on the form. Na Oh rent, West Maine, Maesachusetts, . I, New Hampshire, New Jersey, co, New York, North Carolina, la, Rh d, Texas, Austin, TX 73301 • Me▪ sita, California, Colorado, District of
ma, Arizona, Florida, Georgia, Louisiana, MissIssIppl, North Carolina, Texas, Austin, TX 73301 Arkansas, Connecticut, Delaware, Kentuoky, Maine, Massaohusetts, New Hampshire, Now Jersey, New York, Ohio, Pannsylvaill Rhode Island, Vermont, WeilIllinois, Indiana, Iowa, Kansas, Michigan, Minnesota Missouri
- . . . E c r i ; W I ; . ; . _ _ • 1 - • - • • ^ . - - - • - . • • - . - • - • [ CORNELIUS ' : Ealllitepplabblirms.c.74: rj • ykrifp 7.70.12:3'15irr 4. .• .• el} &TAX': e .. ...: arYV13 100 /6" 14S(.142opatN;10 tautta e6w ; 014.,
ANY, INC. 6100 RED HOOK QUARTER B-3 ST. THOMAS , 00802 d En 580 loyeelt so 13-4697 Clel security number arnagilettf tarns and Inkiel Last norno CORNELIUS 6501 RED HOOK PLAZA FMB 201 ST. THOMAS, VI, 00802 t E d 2le coda SO. Wain] U.S. Virgin Islands Form Wage and Tax Statement Copy 1-For VI
labama, Adzone, Florida. Nolte Louisiana, MissIset49. New Mexico. North Carolina. Texas, UV:girls Adamsro, Connecticut. Delaware Kentucky, Maine, Maseachusetts, New Hampshire, New Jersey, Now York, Ohlo, PonnsyWria. Rhode Wand, Vermont West Veginla Rinds, Indiana, boa, Michigan. Minnesota, Mistroud, Ne
pla-nr • • - ifto Farm W.CAt lions . I Sit 3812.08 10 V ez 09:rn. 14. 14 Oho-- • •-•••••••• 3269.68 «Rgwil 764. SE Agl JAMIE I CORNELIUS I . : E2149:9/2 *Cr. 52 %Icy P70PM .7 f7 :171T ' etS‘4 17.W .4.4e ' 14 - 1. -.4 %4;.•:1•2 :Ara; • trip "kv ••• .A.Z1 V•40:' •••'. age 44.Z
iveld 647.14 7 Semite nounty Mu t eckd =Os number .. .. . . 9 Actincoo EC peryrrort 100 / A • EmPbYeC0 fret nemo old NW trot runts JAMIE I CORNELIUS 11 Nonqualll•d pkvil 12 Forn W483 helrumbrz p 4717.21 e Soo I, tut .... , - 18.10 r 14 Other 12e i rei i A4 e Cr,, mi &Dem •rvi 7JP cod
estate t%barotArIzona, Arkansas, Connelcut, Dalai erne, Georgia, Kentucky, tramactlons; a trustee or Issuer of any Individual retirement Marne, Maesachusetts, . arrangement, a Coverdell ESA, an NSA, an Archer MBA co r • rwo Mi I, Now Hempel-1re, New Jersey, Austin, TX 73301 • Onoluding a Medioese A
MSA); certain corporations; and a Arkansas, Connecticut, Delaware, lender who acquires an Interest In secured property or who has Kentucky, Maine, Massaohusetts, reason to know that the property has been abandoned. New Hampshire, New Jersey, Cincinnati, OH 45999 New York, Ohio, Pennsylvania, Rhode Island
rm W4SS. FTE0003 EFTA00233117 22222 }tollare, n n•imhte P NI mpoyeris name, 3CICM119, andLP coda FINANCIAL 1 Em oat and IP code last name CORNELIUS OMB No. 154-0320 1 Wagea epq ollt7COMPOOSIOSI 2 M Income tax withheld 36501.04 5365.00 3 Soots oacedty wages 4 scaled security tax wiltald 39
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