maxis rot burr (recipleell fa NSA ► 10 Clop Insurance proceeds Y. CO 0 S1141 VALLEY. ACCOunl number (optional) • , 15 2nd TIN not. D 13 FNCOSS golden petaclue payments $ 0 State tax nehhead S 12 ,//// / 14 Gross proceeds pads to an ettomey $ 17 Sate/Payer's stare np le see Interne