te return. Willfully filing a false return is a crime under the Tax Law. Purchasers signature Date Preparers Signature (of other than purchaser) PreParer's address 111 Broadway, 8th Flr. New York, NY 1OOO6 Mail this return and payment to: NYS TAX DEPARTMENT SALES TAX DESK AUDIT CASUAL SALES UNIT

PR Treasury OePertrneot and in such forms accurately &vary dwdenct ardor interest as tat exempt or tate/ale income. Pleat corsult ycur indvdual tax PreParer. February 2016 (S) Year to date IS) Taxable dividends 2,152 85 3,991 14 Taxable interest 0 14 0.14 Total current year $2,152.99 $3,991.28