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he following amount for your filing status: Married filing jointly $250,000 Married filing separately $125,000 Single, Head of household, or Qualifying widow(er) $200,000 5 6 Subtract line 5 from line 4. If zero or less. enter 0- 6 7 Additional Medicare Tax on Medicare wages. Multiply line 6 by 0.9% (0.0

END THIS RECORD TO FinCEN UNLESS REQUESTED TO DO SO. 720011 04.01.17 Rev. 10.7 May 21, 2015 EFTA00792092 ENCLOSE A CHECK FOR $500000, PAYABLE TO THE UNITED STATES TREASURY. INCLUDE YOUR SOCIAL SECURITY NUMBER, DAYTIME PHONE NUMBER, AND THE WORDS "2017 FORM 4868" ON YOUR CHECK. MAIL AS SOON AS POSSIBLE TO: INTERNAL R

he following amount for your filing status: Married filing jointly $250,000 Married filing separately $125,000 Single, Head of household, or Qualifying widow(er) $200,000 9 200,000. 10 Enter the amount from line 4 10 11 Subtract line 10 from line 9. If zero or less. enter .0- 11 200,000. 12 Subtract

END THIS RECORD TO FInCEN UNLESS REQUESTED TO DO SO. 720011 04-01.17 Rev. 10.7 May 21, 2015 EFTA00792182 ENCLOSE A CHECK FOR $500000, PAYABLE TO THE UNITED STATES TREASURY. INCLUDE YOUR SOCIAL SECURITY NUMBER, DAYTIME PHONE NUMBER, AND THE WORDS "2017 FORM 4868" ON YOUR CHECK. MAIL AS SOON AS POSSIBLE TO: INTERNAL R

he following amount for your filing status: Married filing jointly $250,000 Married filing separately $125,000 Single. Head of household, or Qualifying widow(er) $200,000 9 200,000. 10 Enter the amount from line 4 10 11 Subtract line 10 from line 9. If zero or less. enter .0- 11 200,000. 12 Subtract

SEND THIS RECORD TO FinCEN UNLESS REQUESTED TO DO SO. 720011 0441.17 Rev. 10.7 May 21.2015 EFTA00792004 ENCLOSE A CHECK FOR $500000, PAYABLE TO THE UNITED STATES TREASURY. INCLUDE YOUR SOCIAL SECURITY NUMBER, DAYTIME PHONE NUMBER, AND THE WORDS "2017 FORM 4868" ON YOUR CHECK. MAIL AS SOON AS POSSIBLE TO: INTERNAL R