4918, Page 4
Taxpayer FEIN
PART 5: SOuRCE OF FlOW-THROuGH WITHHOlDING PAID ON yOuR BEHAlF By ANOTHER TIER
30.
A.
B.
C.
Allocated/Apportioned
Amount of Withholding
Source Tier Information
Income from line 11
Paid on your Behalf
Business Name
Address
City
State
ZIP/Postal Code
FEIN
Tax Year End (MM-DD-YYYY)
Business Name
Address
City
State
ZIP/Postal Code
FEIN
Tax Year End (MM-DD-YYYY)
Business Name
Address
City
State
ZIP/Postal Code
FEIN
Tax Year End (MM-DD-YYYY)
Business Name
Address
City
State
ZIP/Postal Code
FEIN
Tax Year End (MM-DD-YYYY)
Business Name
Address
City
State
ZIP/Postal Code
FEIN
Tax Year End (MM-DD-YYYY)
Business Name
Address
City
State
ZIP/Postal Code
FEIN
Tax Year End (MM-DD-YYYY)
+
9999 2014 50 04 27 6