5

$

Form 1099-G
PAYER'S Federal identification number RECIPIENT'S identification number 3 Box 2 amount is for tax year 4 Federal income tax withheld

Copy A $

For RECIPIENT'S name

6 Taxable grants

Internal Revenue

Service Center $

File with Form 1096.

For Privacy Act
Street address (including apt. no.)

7 Agriculture payments 8 Check if box 2 is
trade or business

and Paperwork
$
income

Reduction Act City, state, and ZIP code

Notice, see the

2003 General

Instructions for Account number (optional)

Forms 1099, 1098,

5498, and W-2G. Form 1099-G

Cat. No. 14438M

Department of the Treasury - Internal Revenue Service Do Not Cut or Separate Forms on This Page Do Not Cut or Separate Forms on This Page

Exhibit K

2003

Health Insurance Advance

Payments

7171

VOID CORRECTED
PROVIDER'S name, street address, city, state, ZIP code, and telephone no. 1 Gross amount of health OMB No. 1545-XXXX

insurance advance payments
$
2 No. of months eligible

Form 1099-H

Amount of advance payment(s) included in box 1 PROVIDER'S Federal identification number RECIPIENT'S identification number 3 Jan.

9 July $

$ RECIPIENT'S name

4 Feb.

10 Aug. $

$ 5 Mar.

11 Sept.

Copy A

For Internal Revenue

Service Center File with Form 1096.

For Privacy Act and Paperwork

Reduction Act Notice, see the

2003 General Instructions for Forms 1099, 1098, 5498, and W-2G.

$
Department of the Treasury - Internal Revenue Service

Cat. No. 34192D

Do Not Cut or Separate Forms on This Page

Do Not Cut or Separate Forms on This Page

7171

VOID

CORRECTED
PROVIDER'S name, street address, city, state, ZIP code, and telephone no. 1 Gross amount of health OMB No. 1545-XXXX

insurance advance payments
$
2 No. of months eligible

Form 1099-H

Amount of advance payment(s) included in box 1 PROVIDER'S Federal identification number RECIPIENT'S identification number 3 Jan.

9 July

2003

Health Insurance Advance

Payments

Copy A

For Internal Revenue

Service Center File with Form 1096.

For Privacy Act and Paperwork

Reduction Act Notice, see the

2003 General Instructions for Forms 1099, 1098, 5498, and W-2G.

Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page

Do Not Cut or Separate Forms on This Page

2003

Health Insurance Advance

Payments

7171

VOID CORRECTED
PROVIDER'S name, street address, city, state, ZIP code, and telephone no. 1 Gross amount of health OMB No. 1545-XXXX)

insurance advance payments
$
2 No. of months eligible

Form 1099-H
Amount of advance payment(s) included in box 1

3 Jan. PROVIDER'S Federal identification number RECIPIENT'S identification number

9 July $

$ 4 Feb.

10 Aug. RECIPIENT'S name

$

$ 5 Mar.

11 Sept.

Exhibit L

9292

VOID CORRECTED
PAYER'S name, street address, city, state, ZIP code, and telephone no. Payer's RTN (optional)

OMB No. 1545-0112

2003

Interest Income

Form 1099-INT
PAYER'S Federal identification number RECIPIENT'S identification number 1 Interest income not included in box 3

Copy A $

For RECIPIENT'S name

2 Early withdrawal penalty 3 Interest on U.S. Savings Internal Revenue

Bonds and Treas. obligations 1.40"

Service Center

File with Form 1096. $ $

For Privacy Act Street address (including apt. no.)

4 Federal income tax withheld 5 Investment expenses

and Paperwork $ $

Reduction Act
City, state, and ZIP code

6 Foreign tax paid
7 Foreign country or U.S.

Notice, see the possession

2003 General

Instructions for Account number (optional) 2nd TIN not.

Forms 1099, 1098, -2.80"=

5498, and W-2G.

4.15": Form 1099-INT

Cat. No. 14410K

Department of the Treasury - Internal Revenue Service

.60" Do Not Cut or Separate Forms on This Page Do Not Cut or Separate Forms on This Page

9292

VOID CORRECTED
PAYER'S name, street address, city, state, ZIP code, and telephone no. Payer's RTN (optional)

OMB No. 1545-0112

2003

Interest Income

PAYER'S Federal identification number

RECIPIENT'S name

Street address (including apt. no.)

Form 1099-INT
RECIPIENT'S identification number 1 Interest income not included in box 3

Copy A $

For 2 Early withdrawal penalty 3 Interest on U.S. Savings Internal Revenue

Bonds and Treas. obligations Service Center

File with Form 1096. $ $

For Privacy Act 4 Federal income tax withheld 5 Investment expenses

and Paperwork $ $

Reduction Act 6 Foreign tax paid 7 Foreign country or U.S.

Notice, see the possession

2003 General

Instructions for 2nd TIN not.

Forms 1099, 1098, $

5498, and W-2G. Cat. No. 14410K

Department of the Treasury - Internal Revenue Service

City, state, and ZIP code

Account number (optional)

Form 1099-INT

Do Not Cut or Separate Forms on This Page Do Not Cut or Separate Forms on This Page 9292

VOID

O CORRECTED
PAYER'S name, street address, city, state, ZIP code, and telephone no. Payer's RTN (optional)

OMB No. 1545-0112

2003

Interest Income

PAYER'S Federal identification number

RECIPIENT'S name

Exhibit M

4.50"

93936

490 CORRECTED
PAYER'S name, street address, city, state, ZIP code, and telephone no. 1 Gross long-term care

benefits paid

OMB No. 1545-1519

2003

$

Long-Term Care and 2 Accelerated death

Accelerated Death benefits paid

Benefits $

Form 1099-LTC
PAYER'S Federal identification number POLICYHOLDER'S identification number 3 Check one:

INSURED'S social security no.

Copy A Per Reimbursed diem amount 1.40"

For POLICYHOLDER'S name

INSURED'S name

Internal Revenue 3.40"

Service Center

File with Form 1096. Street address (including apt. no.)

Street address (including apt. no.)

For Privacy Act

and Paperwork 2.80"

Reduction Act City, state, and ZIP code

City, state, and ZIP code

Notice, see the

2003 General

Instructions for Account number (optional) 4 Qualified contract 5 Check, if applicable: Chronically ill

Date certified

Forms 1099, 1098, (optional) (optional) Terminally ill

5498, and W-2G. Form 1099-LTC

Cat. No. 23021Z

Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page

- Do Not Cut or Separate Forms on This Page

9393

VOID

CORRECTED
PAYER'S name, street address, city, state, ZIP code, and telephone no. 1 Gross long-term care

benefits paid

OMB No. 1545-1519

2003

o diem

$

Long-Term Care and 2 Accelerated death

Accelerated Death benefits paid

Benefits $

Form 1099-LTC PAYER'S Federal identification number POLICYHOLDER'S identification number 3 Check one:

INSURED'S social security no.

Copy A Per Reimbursed amount

For POLICYHOLDER'S name

INSURED'S name

Internal Revenue

Service Center

File with Form 1096. Street address (including apt. no.)

Street address (including apt. no.)

For Privacy Act and Paperwork

Reduction Act City, state, and ZIP code

City, state, and ZIP code

Notice, see the

2003 General

Instructions for Account number (optional) 4 Qualified contract 5 Check, if applicable:

Chronically ill
Date certified

Forms 1099, 1098,
(optional)
(optional)
Terminally ill

5498, and W-2G. Form 1099-LTC

Cat. No. 23021Z

Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page

Do Not Cut or Separate Forms on This Page

9393

VOID

CORRECTED

1 Gross long-term care PAYER'S name, street address, city, state, ZIP code, and telephone no.

benefits paid

OMB No. 1545-1519

2003

$

Long-Term Care and 2 Accelerated death

Accelerated Death benefits paid

Benefits $

Form 1099-LTC PAYER'S Federal identification number POLICYHOLDER'S identification number 3 Check one:

INSURED'S social security no.

Copy A Per

Reimbursed diem amount

For POLICYHOLDER'S name

INSURED'S name

Internal Revenue

Service Center

File with Form 1096. Street address (including apt. no.)

Street address (including apt. no.)

For Privacy Act and Paperwork

Reduction Act City, state, and ZIP code

City, state, and ZIP code

Notice, see the

2003 General

Instructions for Account number (optional) 4 Qualified contract 5 Check, if applicable: Chronically ill

Date certified

Forms 1099, 1098, (optional) (optional) Terminally ill

5498, and W-2G. Form 1099-LTC

Cat. No. 23021Z

Department of the Treasury - Internal Revenue Service

1.50"

$

$ 15

16 State tax withheld 17 State/Payer's state no. 18 State income $

$ $

$ Form 1099-MISC

Cat. No. 14425J

Department of the Treasury - Internal Revenue Service Do Not Cut or Separate Forms on This Page Do Not Cut or Separate Forms on This Page