taeynenota S 17 StaterOcitar's State no. ill Stale Inootne $ Forrrt 1O99'MISC O VOID D CORRECTED I I Department of the Treasury • Internal Raysnos Wald, PAYER'S name, street address, dly, stele. ZIP coda, end telephoner no. FillatCkal Twat clOMPatTlfr ICC. 1 Reit $ $ S 2 Royalties 3 other In