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Payer:
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| Payer's Federal Identification Number (FIN):043523567 |
| NATIONAL FINANCIAL SERVICES LLC | |
| 499 WASHINGTON BLVD | |
| JERSEY CITY, NJ 07310-0000 | |
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Recipient:
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| Recipient's Identification Number:
551-69-3182 |
| JASON FOX | |
| 758 E WHITEHALL RD | |
| COOKEVILLE, TN 38501-7203 | |
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| Submission Type: | Original document |
| Account Number (Optional): | IX90760199 |
| Interest: | $432.00 |
| Tax Withheld: | $0.00 |
| Savings Bonds: | $0.00 |
| Investment Expense: | $0.00 |
| Interest Forfeiture: | $0.00 |
| Foreign Tax Paid: | $0.00 |
| Tax-Exempt Interest: | $0.00 |
| Specified Private Activity Bond Interest: | $0.00 |
| Market Discount: | $0.00 |
| Bond Premium: | $0.00 |
| Bond Premium on Tax Exempt Bond: | $0.00 |
| Bond Premium on Treasury Obligations: | $0.00 |
| Second Notice Indicator: | No Second Notice |
| Foreign Country or US Possession: | |
| CUSIP Number: | FDIC99128 |
| FATCA Filing Requirement: | Box not checked no Filing Requirement |
