Form 4804 - Transmittal Of Information Returns Reported Magnetically 2001 printable pdf download

Form 4804 - Transmittal Of Information Returns Reported Magnetically 2001

(See Instructions on back)

OMB No.

Department of the Treasury – Internal Revenue Service

IRS Use Only

1545-0367

Transmittal of Information Returns

Form 4804

Reported Magnetically

(Rev. Jan. 2001)

BLACK

Please type or print in

ink.

1. Type of file represented by this transmittal

2. Tax year for which

3. Transmitter control code

media is submitted

(Required)

¨ Test

Original

¨ Correction

Replacement

4. Name of transmitter

5. Name of person to contact regarding problems associated

with the magnetic files.

Telephone number: (

)

6. Name/address of company and name/title of person who should receive correspondence on problem files (street, city,

state, and ZIP code).

Company Name ___________________________________________________________________

Address __________________________________________ City __________________________

State ___________________ ZIP ______________ Contact Person _________________________

E-mail Address ____________________________________________________________________

7. Type of Cartridge

8. Transmitter in-house media number(s)

¨ 18 trk

¨ 36 trk

¨ 128 trk

¨ 256 trk

¨ 4mm

¨ 8mm

¨ QIC

9. Pieces of media associated with this

10. Combined total of payer A records

11. Combined total of payee B records

form

Affidavit

Under penalties of perjury, I declare that I have examined this transmittal, including accompanying documents, and,

to the best of my knowledge and belief, it is correct and complete.

(Normally, the payer must sign the affidavit above. The authorized agent of the payer may sign if all conditions are

met as stated on the back.)

(Required)

IGNATURE

IRS Use Only

Title

Date

Cat. No. 27210I

Form 4804 (Rev. 1-2001)

Form 4804 - Transmittal Of Information Returns Reported Magnetically 2001

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