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agency, or legal Internal Revenue residence in the case of en Service Center individual, Is located In address \Or Alabama, Arizona, Florida, George. Louisiana, Mississippi, New Mexico, North Carolina, Texas, Virginia Martin, -0( 7ssoi Arkansas, Connecticut, Delaware, Kentucky, Maine, Massach
sati two paint 8 Sunittele raymues In Fat Of O./W.(4 of tront 9 Payer rondo dltat so/OS cl 0.050 e
6100 RED HOOK QUARTER 8-3 ST. THOMAS U.S.VIRGIN , 00802 d Employee's social smelly number 580-29-3823 e Ernployee's first name end Inklel Limon MCDONALD MORRELL LORF.,TTA rorrn Meth Isbandss wege and Tax Statement Copy El • For Employer 2004 Department of the Tretsthy • Internal Revenue Servl For Priv
ependent care Innards a Employee's lint name and initial last name Suff. 11 Nonqualltled pans 12a Sae Instructions for box 12 ?, I 13 g1121. W.,'"' liter n n n p-tai I 14 Other 12c ? I 12d 1 Employee's address end ZIP coda leSue Employers state ID number I. 10 Slate wages, lips,
hvolons S 1297.84 d Employee's social security number 580-29-3823 9 Advance EIC payment , a ErIMOTfiriitAltrrno end Initial Last name Suff. MCDONALD MORRELL PO BOX 306077 ST. THOMAS, VI, 00803 f 5m eels address and tpc o 11 Nonavollad lane 13 re 'Z, " Mr 120 • 14 Other 12c 174 0 4 / / rnrm
PIENTS twang Slat. loading a ma * iw4 end ZIP c'edl RECIPIENT'S Idertlicelon number 13-165e110 Serb 0M014.194.0116 S Well. Oetahel S ?lenges W.? 767 Fifty. Alrenee :vow York, ely 10153 Ramat melba @pad 2 Roy, 2003 Fain 1099•MISC 1 Miscellaneous I Income I $ $ 3 Othir (memo a Fs .S
snotty tar vorrhO 1491.96 bladloare na Wthtgl .93 5" 5`""Tilfra .91 7 Boast snally fps ▪ tir e' • Employee's list name arida** LORETTA LAM an MCDONALD MORRELL I Em Fenn Copy 1-Fer VI ta.feaU of Internal Revatur re Copy 0-For Fmptoync es add nd * contra main 22222 9 Advance em payment a VI Welt:A.)
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