. For further information, see Instructions. Name of Income Source Address of Source ' Dates and Brief Description Example: Al! States Company Maintown. TX EXAMPLE Roundtrip air travel from Washington, D.C. to Maintown. TX and lunch for self and spouse for speaking engagement: May 1-3, 200X EXAMP

Address of Source ' Dates and Brief Description Example: Al! States Company Maintown. TX EXAMPLE Roundtrip air travel from Washington, D.C. to Maintown. TX and lunch for self and spouse for speaking engagement: May 1-3, 200X EXAMPLE 1 2 3 4 5 6 7 8 9 10 11 12 13 I EFTA_R1_01522039 E