Medimre tax wahherci 11750.58 e *IIIIIII.ar(EIN) 7 Social °county Au ft 7 f Empbyeras name FINANCIAL T C. 9 Advance BIC payments 10 L - 11 Nonqualelad plans IR Debarred compensation 39945.62 la For thercruarty obit pay use only g Emprousle address end ZIP node 14 income tax witted by payer of th