Filer's Name @error('filer_name') {{ $message }} @enderror

Street address

City/Town

State/Province

Country

Zip/Foreign postal code

Telephone no

Check to indicate if FILER is a (an)

Payment Settlement Entity (PSE)

Electronic Payment Facilitator (EPF) / Other third party

Check to indicate transactions reported are

Payment card

Third party network

Service Provider Name*

Street address

Apt.no

City/town

State/province

Country

ZIP/foreign postal code

Enter Account no

Telephone number no

FILER’S TIN

PAYEE’S TIN

1a Gross amount of payment card/third party network transactions

1b Card Not Present transactions

2 Merchant category code transactions

3 Number of payment transactions

4 Federal income tax withheld

5a January

$

5a February

$

5c March

$

5d April

$

5e May

$

5f June

$

5g July

$

5h August

$

5i September

$

5j October

$

5k November

$

5l December

$

6 State

7 State identification no.

8 State income tax withheld

For calendar year

Add Tax