ZIP code West Palm Beach, PI, 33407 Account number (optional) IS 2nd TIN AM O 13 Excess °Olen parachute 14 Gross proceeds paid 10 payments an IttIcencry $ $ 16 State tax withheld 17 State/Payer's mate rte $ $ For Privacy Act and Paperwork Reduction Act Notice, see the 2003 General Instruct