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instructions) 2 Empire State child credit (from Form IT-201, fine 63) 3 NYS/NYC child and dependent care credit (from Form IT-201, line 64) 4 NY State earned income credit (EIC) (from Form IT-201, line 65) 5 NY State noncustodial parent EIC (from Form IT-201, fine 66) 6 Real property tax credit
1 s 1T-201LATT Name(s) as shown on your Form IT•201 ANASTASIYA SIROOCHENKO A Have you (or an entity of which you are an owner) been convicted of Bribery Involving Public Servants and Related Offenses, Corrupting the Government, or Defrauding the Government (NYS Penal Law Article 200. 496. or section 195.20)? (see instruction
instructions) 2 Empire State child credit (from Form IT-201, fine 63) 3 NYS/NYC child and dependent care credit (from Form IT-201, fine 64) 4 NY State earned income credit (EIC) (from Form IT-201, line 65) 5 NY State noncustodial parent EIC (from Form IT-201, fine 66) 6 Real property tax credit
shown on your FormIT.201 ANASTASIYA SIROOCHENKO Your social security number. A Have you (or an entity of which you are an owner) been convicted of Bribery Involving Public Servants and Related Offenses, Corrupting the Government, or Defrauding the Government (NYS Penal Law Article 200. 496. or section 195.20)? (see instruction
N) ***** 9816 2 Empire State child credit (from Form IT-201, fine 63) 3 NYS/NYC child and dependent care credit (from Form IT-201, fine 64) 4 NY State earned income credit (EIC) (from Form IT-201, Nne 65) 5 NY State noncustodial parent EIC (from Form IT-201, fine 66) 6 Real property tax credit (
your Form IT•201 Your social security number ANASTASIYA SIROOCHENKO 9816 A Have you (or an entity of which you are an owner) been convicted of Bribery Involving Public Servants and Related Offenses, Corrupting the Government, or Defrauding the Government (NYS Penal Law Article 200, 496. or section 195.20)? (see instruction
Entities connected to both NY State and Bribery Involving Public Servants

New York State
LOCATION
New York
LOCATION
the Internal Revenue Service
ORGANIZATION
United States
LOCATIONINTERNAL REVENUE SERVICE CENTER
ORGANIZATION
Empire State
LOCATIONBreast Cancer Research Fund
ORGANIZATIONFirst Installment
ORGANIZATIONMaria Farmer
PERSONSpouse
ORGANIZATIONPersonal Income Tax Information Center
ORGANIZATIONthe New York State Tax Department
ORGANIZATIONWomen's Cancers Education and Prevention Fund
ORGANIZATIONTHE NY TAX DEPT
ORGANIZATIONNYC-210
ORGANIZATIONNY City
LOCATIONthe New York State Department of Taxation and Finance
ORGANIZATIONYonkers
LOCATIONPreparer
ORGANIZATIONFiler
PERSON