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Ore in these four boxes: Please print or type the name and address of the payor in the box below: FORM LY LY N L S O ICA E OS RON P Commission N.E.C. Payments Rents Other R Interest Dividends CT U IncomeE(specify) P L AL D E N Do not use this form to report Recipient s Payor s Federal Identification Number IO Identification LE Number I T F salaries and wages. A E M Use optional Form W-2: Internal R TB O Please print or type the recipient s name, address, and ZIP in the area below: Reven.

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