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above P"' Taxable refunds, credits, or offsets of state and local income taxes Alimony received Business income or (loss). Attach Schedule C or C-EZ Capital gain or (loss). Attach Schedule D if required. If not required, check here ► 7 8a 740. 9a 10 11 12 13 14 15b 16b 17 18 19
AMOUNT OF AUTHORIZED DEBIT: FINANCIAL INSTITUTION ROUTING NUMBER: FINANCIAL INSTITUTION ACCOUNT NUMBER: Part A - Declaration and authorization of Taxpayer for Forms NYC-202, NYC-202S, NYC-EXT or NYC-5UBT1 Under penalty Unincorporated knowledge and electronically Internal Revenue Business Tax New York City designated financ
through 35 Taxable refunds, credits, or offsets of state and local income taxes Alimony received Business income or (loss). Attach Schedule C or C-EZ ► 7 8a 755. 9a 10 11 12 13 14 15b 16b 17 18 19 20b 21 22 1,645,828. ► 1,646,583. Adjusted Gross Income 23 24 25 26 2
AMOUNT OF AUTHORIZED DEBIT: FINANCIAL INSTITUTION ROUTING NUMBER: FINANCIAL INSTITUTION ACCOUNT NUMBER: Part A - Declaration and authorization of Taxpayer for Forms NYC-202, NYC-202S, NYC-EXT or NYC-5UBT1 Under penalty Unincorporated knowledge and electronically Internal Revenue Business Tax New York City designated financ
ets of state and local income taxes 10 1099-R if tax was withheld. 11 Alimony received 11 12 Business income or (loss). Attach Schedule C or C-EZ 12 13 Capital gain or (loss). Attach Schedule D U required. If not required, ohm* here 13 If you did not get a W-2, 14 Other gains or (los
AMOUNT OF AUTHORIZED DEBIT: FINANCIAL INSTITUTION ROUTING NUMBER: FINANCIAL INSTITUTION ACCOUNT NUMBER: Part A - Declaration and authorization of Taxpayer for Forms NYC-202, NYC-202S, NYC-EXT or NYC-5UBTI Under penalty Unincorporated knowledge and electronically Internal Revenue Business Tax New York City designated financ
Entities connected to both C-EZ and Taxpayer for Forms NYC-202, NYC-202S

U.S. Treasury
ORGANIZATIONthe Foreign Earned Income Tax Worksheet
ORGANIZATIONSchedule SE
PERSONthe U.S. Treasury Financial Agent
ORGANIZATION
United States
LOCATIONERO Signature
ORGANIZATIONSpouse
ORGANIZATION
FinCEN
ORGANIZATIONConservation Reserve
ORGANIZATIONJurat/Disclosure
ORGANIZATIONConservation Reserve Program
ORGANIZATIONUtilities
ORGANIZATIONFiler
PERSONU.B.T.
ORGANIZATION
New York State
LOCATION
Empire State
LOCATIONthe Dept. of Finance
ORGANIZATIONJohn O. Smith
PERSONthe New York State Tax Department
ORGANIZATIONWomen's Cancers Education and Prevention Fund
ORGANIZATION