Form 4804 - Transmittal Of Information Returns Reported Magnetically/electronically
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14804
OMB No. 1545-0367
Transmittal of Information Returns
Form
IRS Use Only
Reported Magnetically/Electronically
(Rev. April 1997)
Department of the Treasury
(Please type or print clearly in BLACK ink.)
Internal Revenue Service
1
Type of files represented by this transmittal
2
Tax year for
3
Transmitter control code (TCC) assigned by IRS (Required)
which media is
Original
Replacement
submitted
Test
Correction
4
Name of transmitter
5
Name of person to contact regarding magnetic/electronic files
Telephone number (
)
6
Name/address of company and name/title of person to whom
7
Type of media filed
problem files are to be returned (street, city, state, and ZIP code)
9 track tape
3-1/2" diskette
5-1/4" diskette
7a
(Tape cartridge filers only)
Name
36 track
18 track
4 mm
8 mm
QIC
Contact
7b
(Electronic filers only)
3780 Protocols
IRP-BBS: File name:
Address
Total pieces of magnetic
Combined total of payee records
8
9
media in shipment
from section 10 and any attached
City
State
ZIP
Forms 4802
Please use this section to report information for up to five types of returns and/or payers. If additional space is
10
needed, please use Form 4802, Transmittal of Information Returns Reported Magnetically/Electronically (Continuation).
Employer Identification
Total Payee
Transmitter’s
Name of Payer
Type of Return
Number
Records
Media No.
Affidavit
IRS Use Only
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.
(Nor mally, the payer must sign the affidavit above. The
author ized agent of the payer may sign if all conditions are met
as stated on the back. )
Signature (Required)
Title
Date
4804
For Paperwork Reduction Act Notice, see back of form.
Cat. No. 27210I
Form
(Rev. 4-97)
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