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Form 1096 Annual Summary and Transmittal of OMB No. 1545 - 0108

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Department of the Treasury
U.S. Information Return 2021

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Internal Revenue Service

FILER'S name, street address, city or town, state or province, country, ZIP or foreign

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postal code

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US TREASURY
1111 CONSTITUTION AVE NW

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WASHINGTON DC 20224
US

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Name of person to contact Telephone number

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US TREASURY 2026222000 For Official Use Only

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Email address Fax number
TREASURY.DIRECT@FISCAL.TREASURY.GOV N/A
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1. Employer identification number 2. Social security number 3. Total number of forms 4. Federal income tax withheld 5. Total amount reported with this form 1096
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520907065 1 24,000.00
$ 0.00 $
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6. Enter an "X" in only one box below to indicate the type of form being filed. 7. If this is your final return an "X" here........
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W-2G 1097-B 1098 1098-C 1098-E 1098-T 1099- 1099-B 1099-C 1099- 1099- 1099-G 1099-H 1099- 1099-K 1099- 1099- 1099-N
32 TC 81 78 84 83 A 79 85 CAP DIV 86 71 INT 10 LTC MISC EC
50 80 73 91 92 93 95 71

o o o o o o þ o o o o o o o o o o o
1099- 1099- 1099-Q 1099-R 1099-S 1099-S 3921 3922 5498 5498- 5498-
OID PATR 31 98 75 A 25 26 28 ESA SA
96 97 94 72 27

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Under the penalties of prejury, I declare that I have examined this return and accompanying documents, and, to the best of my knowledge and belief, they
are true, correct, and complete.

Signature Title Date

Form - 1096 www.tax1099.com - IRS approved e-file provider