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mated tax, and the financial institution to debit the entry to this account. This authorization is to remain in full force and effect until I notify the U.S. Treasury Financial Agent to terminate the authorization. To revoke (cancel) a payment I must contact the U.S. Treasury Financial Agent at 1-888-353-4537. Payment cancellatio
line 36 from line 22. This is your adjusted gross Income 37 Last name (2)Orneridenre Serial security number O.04endenEs relatkentalp 10 you Boxes aced on Ea and Ea No of children thig 6c ho. min age 17 p lend with you 1004019 NI hr4 did not Ma with grardt you due tO Ovate a Separatio
mated tax, and the financial institution to debit the entry to this account. This authorization is to remain in full force and effect until I notify the U.S. Treasury Financial Agent to terminate the authorization. To revoke (cancel) a payment, I must contact the U.S. Treasury Financial Agent at 1-888-353-4537. Payment cancellati
ndents social way numb. (310ependenrs m you asonsuo to IAm o Al Mid iallUil fleichl iaw 17 wow SON X d Total number of exemptions claimed Boxes checked en Ca and (1b No. of children on 6c who: * Ned with you • did nettle., with you OA to &KW9 Cr separation lane rtstructmal Oroenclant
imated tax, and the financial institution to debit the entry to this account This authorization is to remain in full force and effect until I notify the U.S. Treasury Financial Agent to terminate the authorization. To revoke (cancel) a payment, I must contact the U.S. Treasury Financial Agent at 1.888-353-4537. Payment cancellati
ttach Schedule D if required. If not required, check here Other gains or (losses). Attach Form 4797 IRA distnbutians 1 151 I b Taxable amount Boxes checked on 6a and Etc No 01 children o 6c tio. *Pad with you %did not We with you due to OlvOrCe a Separation InStructiathl Dapanden% on 6c
Entities connected to both the U.S. Treasury Financial Agent and Boxes

U.S. Treasury
ORGANIZATION
United States
LOCATIONERO Signature
ORGANIZATIONC-EZ
ORGANIZATIONSchedule SE
PERSONSpouse
ORGANIZATIONthe Foreign Earned Income Tax Worksheet
ORGANIZATION
Joi Ito
PERSONFiler
PERSONUtilities
ORGANIZATIONConservation Reserve
ORGANIZATIONConservation Reserve Program
ORGANIZATION
FinCEN
ORGANIZATIONJurat/Disclosure
ORGANIZATIONBox B
ORGANIZATIONBox E
ORGANIZATIONBox F
ORGANIZATIONSchedules 0
ORGANIZATIONIndividual, Estate
ORGANIZATIONExchanges of Property
ORGANIZATION