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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
certify that this return, Including any accompanying rider, is, to the best of my knowledge and belief, true, correct fin' and complete. I authorize the Dept. of Finance to discuss this return with the preparer listed below. (See Instr.) YES X man AllariltS9 SIGN HERE: Seamier° of laxpirear Tali) Data Presort(
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
reby certify that this return, including any accompanying rider, is, to the best of my knowledge and belief, true, correct and complete. I authorize the Dept. of Finance to discuss this return with the preparer listed below. (See Instr.) YES X Fin's Email Merin: SIGN HERE: Signature of taxPirra' Date Wenn(' sae
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
at this return, including any accompanying rider, is, to the best of my knowledge and belief, true, correct Firwsernmmosst and complete. I authorize the Dept. of Finance to discuss this return with the preparer listed below. (See Instr.) YES X INFO@DAVI DWE I S SCP SIGN HERE: Secretor° of !tapir/or Trio Data P
Entities connected to both THE UNITED STATES TREASURY and the Dept. of Finance
NYC-210
ORGANIZATION
New York State
LOCATIONNYS/NYC
ORGANIZATION
Empire State
LOCATIONKICTIM
ORGANIZATIONBreast Cancer Research Fund
ORGANIZATION60e Olympic Fund
ORGANIZATIONthe U.S. Treasury Financial Agent
ORGANIZATIONVeterans'
ORGANIZATIONBribery Involving Public Servants
ORGANIZATIONDefrauding the Government
ORGANIZATIONTotal New York State
ORGANIZATIONWorksheet A
ORGANIZATIONForm IT-20VATT
ORGANIZATIONFirst Installment
ORGANIZATIONSecond Installment
ORGANIZATIONU.B.T.
ORGANIZATIONConservation Reserve Program
ORGANIZATIONSpouse
ORGANIZATIONthe New York State Tax Department
ORGANIZATION