InStrance preceedS $ 12 14 Gross proceeds paid to an snorer/yr 17 State/Payer's state no. 19 State Income $ I Other Income PAYER'S Federal Identtelko master 66-0567418 RECIPIENT'S neme address, and ZIP code RECIPIENT'S Identif.nnon malty 66-0'136649 front, HOVPW,M, PC pp DOX SiO CHPARLOTTS