Final Test: Part II, Case Study

Bruce and Lois Harrison

After completing the required forms for the mini problems, you are now ready to prepare the case study return.

Using the information below, complete a 2019 tax return for Bruce and Lois Harrison. Read the scenario carefully before beginning.

Once you complete the return to your satisfaction, enter Block Academy, and access the Final Test. You will need to reference the return to answer questions on the Final Test, so be sure to keep a copy of the return.

Instructions

You should prepare the return by hand. You will find the forms you need in the workbook. If you prefer using online, fillable forms, click on the links at the end of this case study to access the forms.

Taxpayer Information

Taxpayer name:	Bruce H. Harrison
Taxpayer SSN:	201-00-0045
Taxpayer DOB:	April 1, 1977
Taxpayer occupation:	Contractor
Spouse name:	Lois A. Harrison
Spouse SSN:	201-00-1451
Spouse DOB:	March 28, 1982
Spouse occupation:	Newscaster
Address:	1312 Locust Street
	Your City, YS XXXXX
Cell phone (T):	(XXX) 555-6336; Preferred: Anytime; FCC: Yes; OK to call
Cell phone (S):	(XXX) 555-6363; Anytime; FCC: Yes; OK to call
Taxpayer email:	bhharrison@net.net
Spouse email:	lharrison@net.net
Health Insurance Information
Did everyone in the household have health insurance in 2019?		Yes
Total months covered through a state exchange or federal marketplace:		0
Total months covered through an employer-sponsored plan:		12
Was a Form 1095-A issued?		No

Bruce and Lois Harrison are new clients. Last year, they prepared their own return using online software, but this year, they would like professional assistance. They are married and wish to file a joint tax return. Both of their SSNs are valid for work in the U.S. and were received before the original filing due date of their return (including extensions). Both are U.S. citizens. No one may claim them as dependents. Neither is a student. They both wish to designate $3 to the Presidential Election Campaign Fund. Neither is blind or disabled.

Bruce and Lois did not suffer any casualty losses during the current tax year. They did not receive, sell, send, exchange, or otherwise acquire any financial interest in any virtual currency. Neither Bruce nor Lois have a financial interest in or signature authority over a foreign account. They did not receive a distribution from, nor were they the grantors of or transferor to, a foreign trust. The IRS has not issued any Identity Protection ID Numbers for their return.

They did not receive a notice from the IRS or any state or local taxing authority within the last year. Neither Bruce nor Lois provide a drivers license or state identification.

Household Information

Bruce and Lois own their home. They have two children.

Dependent name:	Lyla B. Harrison
Dependent SSN:	201-00-2451
Dependent DOB:	July 12, 2014
Dependent relationship:	Daughter
Time in household:	12 months
Gross income:	$0
Support:	Does not provide over half of her own support
Dependent name:	Kevin E. Harrison
Dependent SSN:	201-00-2452
Dependent DOB:	October 15, 2016
Dependent relationship:	Son
Time in household:	12 months
Gross income:	$0
Support:	Does not provide over half of his own support

Lyla and Kevin lived with Bruce and Lois all year, and they did not have any income. Neither is married or disabled. They are both U.S. citizens. Lyla and Kevin have SSNs that are valid for work in the United States and were received before the due date for the return (including extensions). Bruce and Lois brought in copies of medical records for both children.

Adjustments

Lois contributed $2,500 to a traditional IRA during the year. She only has one IRA account, and the value of this account on December 31, 2019, was $13,097.85. All of her previous contributions were deductible. Lois has never taken a distribution from this or any other retirement account. Bruce is covered by an employer-sponsored retirement plan, but Lois is not.

Credits

Bruce and Lois paid Little Ones Learning Center $7,200 ($3,600 for each child) to care for Kevin and Lyla while they worked. The center's EIN is 09-2014501. It is located at 1521 West Plain Road, Your City, YS XXXXX. The phone number for the Center is (XXX) 555-0034. Bruce and Lois have documentation substantiating this expense.

Self-Employment Income

Lois has always been an avid reader, and during the year, she had an opportunity to lead a book club at a nearby community center. The community center paid Lois for this work. At the end of the year, they sent Lois a Form 1099-MISC reporting an amount for nonemployee compensation in box 7 of the form. This form is shown in the Information Documents section. The community center is within walking distance of the couple's home, so Lois did not have any vehicle or travel expenses. Her only business-related expense was for $225 in supplies.

For purposes of the qualified business income deduction (QBID), this is not a specified service trade or business (SSTB). Lois did not pay any qualified wages, nor does she have any qualified business property, or any losses or short-term gains from asset disposition.

Capital Assets

Bruce was unhappy with the performance of an investment he had made in 2017. He sold the shares of stock on November 7, 2019, for fear the stock would continue its downward trend. Information relating to this sale was reported on a Form 1099-B. This form is shown in the Information Documents section.

Itemized Deductions

Bruce and Lois want to itemize deductions if it will be more beneficial than taking the standard deduction. They bring a Form 1098 reporting mortgage interest and real estate taxes paid on their personal residence. This is shown in the Information Documents section. Bruce and Lois would prefer to take the state income tax deduction rather than the sales tax deduction. They also had the following potentially deductible items for 2019:

Item	Amount	Notes
2018 State Balance Due	$582	Made this payment on April 10, 2019
Cash donation to Cancer Research Foundation	$475	Paid March 4, 2019

INFORMATION DOCUMENTS UPLOADED

PLEASE COMPLETE SCHEDULE SE

a Employee's social secunty number XXX-XX-0045 b Employer identification number EIN) 09-2014502 c Employer's name, address, and ZIP code ELM CONSTRUCTION AGENCY 6 GREENWOOD LANE YOUR CITY, YS XXXXX Sate, accurate, Visit the IRS website at OMB No 1545-0008 FAST! Use urse - file www.ss.govladie 1 Wages, tips, other compensation 2 Federal income tax withheld 39,950.00 2,671.05 3 Social Security wagos 4 Social security face withhold 42,950.00 2,662.90 5 Medicaro wagos and tips 6 Medicare tax withhold 42,950.00 622.78 7 Social Security tp8 8 Allocated tips d Control number 9 10 Dependent care benefits e Employee's first name and initial Last name Suff. 11 Nonqual fied plans 12a See instructions for box 12 DD 17,485.00 13 Statutory englove Third-party ray 12b BRUCE H. HARRISON 1312 LOCUST STREET YOUR CITY, YS XXXXX Retirement X D 3,000.00 14 Other 12c 12d *000 1 Employee's address and ZIP code 15 State Employer's state ID number YS 490020210A 18 Local wages, tips, co. 19 Local income tax 20 Locality name 16 State wages, tips, do 39,950.00 17 State income tax 2,197.25 Department of the Treasury - Internal Revenue Service 2019 Form Statement Copy B-To Be Filed With Employee's FEDERAL Tax Return This information is being furnished to the Internal Revenue Service. a Employee's social secunty number 201-00-1451 b Employer identif cation number EIN) 09-2014503 c Employor's name, addross, and ZIP code LOCAL NEWS NETWORK 112 NORTHERN STREET YOUR CITY, YS XXXXX Safe, accurate, Visit the IRS website at OMB No 1545-0008 FAST! Use re- file www.is.govlenie 1 Wages, tips, other compensation 2 Federal income tax withheld 44,500.00 3,517.79 3 Social Security wagos 4 Social security tax withhold 44,500.00 2,759.00 6 Medicare wages and tips 6 Medicare tax withhold 44,500.00 645.25 7 Social security tp8 8 Allocated tips d Control number 9 10 Dependent care benefits Employee's first name and initial Last name Suff. 11 Nonquaified plans 12a See instructions for box 12 13 Statutory ago Petirement Third-party say 12b 8 LOIS A. HARRISON 1312 LOCUST STREET YOUR CITY, YS XXXXX 14 Other 12c 12d 1 Employee's address and ZIP code 15 State Employer's state ID number YS 490020211A 18 Local wages, tips, etc. 16 State wages, tips, to 44,500.00 19 Local income tax 20 Locality name 17 State income tax 2,447.50 Department of the Treasury-Internal Revenue Service W-2 Wage and Tax Form 2019 Copy B-To Be Filed With Employee's FEDERAL Tax Return This information is being furnished to the Internal Revenue Service. OMB No. 1545-01 15 2019 CORRECTED (if checked) PAYER'S name, street address, city or town, state or province, country, ZIP Rents or foreign postal code, and telephone no. NEIGHBORHOOD COMMUNITY CENTER 2 Royalties 1511 CHERRY STREET YOUR CITY, YS XXXXX 816-555-XXXX 3 Other income PAYER'S TIN 5Fishing bout proceeds Miscellaneous Income Form 1099-MISC 4 Federal income tax withheld Copy B For Recipient RECIPIENT'S TIN 6 Medical and health care payments $ 1,550.00 09-2014504 201-00-1451 RECIPIENT'S name 7 Nonemployee compensation 8 Substitute payments in lieu of dividends or inforest This is important tax LOIS A. HARRISON information and is being furnished to Street address (induding apt. no.) $ the IRS. If you are 9 Payer made direct sales of 10 Crop insurance proceeds required to file a 1312 LOCUST STREET $5,000 or more of consumer return, a negligence products to a buyer penalty or other City or town, stato or province, country, and ZIP or foreign postal code (recipen for resale O $ sanction may be 11 imposed on you if 12 YOUR CITY, YS XXXXX this income is taxable and the IRS Account raumber (sce instructions) FATCA fling 13Excess golden parachute 14 Gross proceeds paid to an determines that it requirement payments attorney has not been reported. $ $ 15a Section 409A deferrals 15b Section 400A income 16 State tax withheld 17 StatoPayer's state na 18 State income $ $ $ Form 1099-MISC (keep for your records) www.irs gov/Form 1099MISC Department of the Treasury - Internal Revenue Service CORRECTED (if checked) CORRECTED (if checked) PAYER'S namo, street address, city or town, state or province, country, ZIP Applicable checkbox on Form 2049 OMB No 1545-0715 Proceeds From or foreign postal code, and telephone no. D I TRADE ONLINE INVESTMENTS 2019 Barter Exchange Broker and 5621 LA HABRA PARKWAY, STE 13 Form 1099-B Transactions YOUR CITY, YS XXXXX 1a Description of property (Example: 100 sh. XYZ Co.) 816-555-XXXX 100 SHARES ALX 1b Date acquired 1c Date sold or disposed 05/05/2017 11/01/2019 PAYER'S TIN RECPENT'S TIN 1d Proceeds 1e Cost or other basis $ 2,700.00 $ 3,100.00 For Recipient 09-2014505 XXX-XX-0045 1f Accrued market discount 1g Wash sale loss disallowed $ |$ RECIPIENT'S name 2 Short-term gain or loss 3 I checked, proceeds from: BRUCE H. HARRISON Long-term gain or loss Collectibles Ordinary QOF This is important tax Street address including apt. no.) 4 Federal income tax withheld 5 I checked, noncovered information and is $ security being furnished to 1312 LOCUST STREET 6 Roported to RS: 7 If checked, loss is not allowed the IRS. If you are City or town, state or province, country, and ZP or foreign postal code required to file a based on amount in 1d Gross proceeds return, a negligence YOUR CITY, YS XXXXX Net proceeds penalty or other 8 Profit or loss) realized in 9 Unrealized profit or foss) on sanction may be Account number (see instruction) 2019 on closed contracts open contracts - 12/31/2018 imposed on you it this income is 12-34567891 $ taxable and the IRS CUSIP number FATCA fling 10 Unrealized profit or loss on 11 Aggregate profit or foss) determines that it requirement open contracts - 12/31/2019 on contracts has not been 14 State name 15 State identification no. 16 State tax withheld $ reported. 12 I checked, basis reported 13 Bartering to IRS Form 1099-B (Keep for your records) www.irs.gov/Form 1000B Department of the Treasury - Internal Revenue Service . RECIPIENTS/LENDER'S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no. REALTY MORTGAGE COMPANY 691 PLEASANT GROVE YOUR CITY, YS XXXXX XXX-555-XXXX RECIPIENTS/LENDER'S TIN PAYER'S BORROWER'S TIN 09-2014506 XXX-XX-0045 Caution: The amount shown may OMB No. 1545-1380 not be fully deductible by you. Limits based on the loan amount 2019 and the cost and value of the Mortgage secured property may apply. Also, Interest extent i was incurred by you Statement actually paid by you, and nol reimbursed by another person Form 1098 1 Mortgage interest received from payer(s)/borrower(s)" Copy B $ 8,241.64 For Payer/ 2 Outstanding mortgage 3 Mortgage origination date Borrower principal $ 125,067.00 05/04/2014 The information in boxes 1 4 Refund of overpad through 9 and 11 is important 5 Mortgage insurance interest premiums tax information and is being turnished to the IRS. If you are $ $ required to file a return, a 6 Points paid on purchase of principal residence negligence penaty or other $ sanction may be imposedon you if the IRS determines that 7 X l address of property securing mortgage is the same an underpayment of tax as PAYER'S/BORROWER'S address, the box is checked, ar results because you the address or description is entered in box 8. overstated a deduction for this mortgage interest or for 8 Address or description of property securing mortgage (see these points, reported in instructions) boxes 1 and 6: or because you didn't report the round of interest (box 4; or because you claimed a nondeductible PAYER'S/BORROWER'S name BRUCE AND LOIS HARRISON Street address including apt. no.) 1312 LOCUST STREET City or town, state or province, country, and ZIP or foreign postal code YOUR CITY, YS XXXXX 9 Number of properties securing the 10 Other mortgage RE TAX: $2,315 Account number (see instructions) 11 Mortgage acquisition dale Form 1098 Keep for your records) www.is.gov/Form 1098 Department of the Treasury - Internal Revenue Service SLOl18 Zon SLOL18 rm1095-B Health Coverage VOD OMB No 1545-7252 Department of the Try Do not attach to your tax return. Keep for your records. CORRECTED 2019 Internal Revenue S Go to www.irs.gov/Form 10958 for instructions and the latest Information Part 1 Responsible Individual 1 Name of responsable dnius-First name, rade name, last name 2 Social security number (SSR or other TN 3 Date of birth it SSN or other TN is not available) BRUCE H. HARRISON XXX-XX-0046 4 Standing apartment no 5 City or town 7 Courtyard Perforen postal code 1312 LOCUST STREET YOUR CITY YS USA XXXXX Enter letter identitying Origin of the Health Coverage (see instructions for codes B Part II Information About Certain Employer-Sponsored Coverage (see instructions) 10 Employer rano 11 Employer identification number (EN ELM CONSTRUCTION AGENCY 09-2014502 12 Shroot address ang room or su 13 City or town 14 State 15 Country and Pas forcegn portal code 6 GREENWOOD LANE YOUR CITY YS USA XXXXX Part III Issuer or Other Coverage Provider (see instructions) 16 Name 17 Employer identification number 18 Contact telephone number GENERAL INSURANCE COMPANY 09-2014507 (XXX) 562-5543 10 Great add chodno tome watero) 20 Cayor town 22 Country and ZP or for postal code 1776 TURNBULL CANYON YOUR CITY YS USA XXXXX Part IV Covered Individuals (Enter the information for each covered individual.) (a) Name of covered individu SSN other TN008 ISSN Goes Covered el Moto Testame, middle arome TN is related Jan Feb Mar Apr May Jun JU Aug Sep Oct Dec DOO X OD H. HARRISON XXX-XX-0045 NO BRUCE 24 LOIS A. HARRISON 201-00-1451 X 000000000000 o OOO OOD X 25 B. HARRISON 201-00-2451 LYLA KEVIN 26 E. HARRISON 201-00-2452 X OO DOO D D 27 O ODOO OOOOO 28 For Privacy Act and Paperwork Reduction Act Notice, se separate instructions. Cut N 00185 Form 1096-B 2016 a Employee's social secunty number XXX-XX-0045 b Employer identification number EIN) 09-2014502 c Employer's name, address, and ZIP code ELM CONSTRUCTION AGENCY 6 GREENWOOD LANE YOUR CITY, YS XXXXX Sate, accurate, Visit the IRS website at OMB No 1545-0008 FAST! Use urse - file www.ss.govladie 1 Wages, tips, other compensation 2 Federal income tax withheld 39,950.00 2,671.05 3 Social Security wagos 4 Social security face withhold 42,950.00 2,662.90 5 Medicaro wagos and tips 6 Medicare tax withhold 42,950.00 622.78 7 Social Security tp8 8 Allocated tips d Control number 9 10 Dependent care benefits e Employee's first name and initial Last name Suff. 11 Nonqual fied plans 12a See instructions for box 12 DD 17,485.00 13 Statutory englove Third-party ray 12b BRUCE H. HARRISON 1312 LOCUST STREET YOUR CITY, YS XXXXX Retirement X D 3,000.00 14 Other 12c 12d *000 1 Employee's address and ZIP code 15 State Employer's state ID number YS 490020210A 18 Local wages, tips, co. 19 Local income tax 20 Locality name 16 State wages, tips, do 39,950.00 17 State income tax 2,197.25 Department of the Treasury - Internal Revenue Service 2019 Form Statement Copy B-To Be Filed With Employee's FEDERAL Tax Return This information is being furnished to the Internal Revenue Service. a Employee's social secunty number 201-00-1451 b Employer identif cation number EIN) 09-2014503 c Employor's name, addross, and ZIP code LOCAL NEWS NETWORK 112 NORTHERN STREET YOUR CITY, YS XXXXX Safe, accurate, Visit the IRS website at OMB No 1545-0008 FAST! Use re- file www.is.govlenie 1 Wages, tips, other compensation 2 Federal income tax withheld 44,500.00 3,517.79 3 Social Security wagos 4 Social security tax withhold 44,500.00 2,759.00 6 Medicare wages and tips 6 Medicare tax withhold 44,500.00 645.25 7 Social security tp8 8 Allocated tips d Control number 9 10 Dependent care benefits Employee's first name and initial Last name Suff. 11 Nonquaified plans 12a See instructions for box 12 13 Statutory ago Petirement Third-party say 12b 8 LOIS A. HARRISON 1312 LOCUST STREET YOUR CITY, YS XXXXX 14 Other 12c 12d 1 Employee's address and ZIP code 15 State Employer's state ID number YS 490020211A 18 Local wages, tips, etc. 16 State wages, tips, to 44,500.00 19 Local income tax 20 Locality name 17 State income tax 2,447.50 Department of the Treasury-Internal Revenue Service W-2 Wage and Tax Form 2019 Copy B-To Be Filed With Employee's FEDERAL Tax Return This information is being furnished to the Internal Revenue Service. OMB No. 1545-01 15 2019 CORRECTED (if checked) PAYER'S name, street address, city or town, state or province, country, ZIP Rents or foreign postal code, and telephone no. NEIGHBORHOOD COMMUNITY CENTER 2 Royalties 1511 CHERRY STREET YOUR CITY, YS XXXXX 816-555-XXXX 3 Other income PAYER'S TIN 5Fishing bout proceeds Miscellaneous Income Form 1099-MISC 4 Federal income tax withheld Copy B For Recipient RECIPIENT'S TIN 6 Medical and health care payments $ 1,550.00 09-2014504 201-00-1451 RECIPIENT'S name 7 Nonemployee compensation 8 Substitute payments in lieu of dividends or inforest This is important tax LOIS A. HARRISON information and is being furnished to Street address (induding apt. no.) $ the IRS. If you are 9 Payer made direct sales of 10 Crop insurance proceeds required to file a 1312 LOCUST STREET $5,000 or more of consumer return, a negligence products to a buyer penalty or other City or town, stato or province, country, and ZIP or foreign postal code (recipen for resale O $ sanction may be 11 imposed on you if 12 YOUR CITY, YS XXXXX this income is taxable and the IRS Account raumber (sce instructions) FATCA fling 13Excess golden parachute 14 Gross proceeds paid to an determines that it requirement payments attorney has not been reported. $ $ 15a Section 409A deferrals 15b Section 400A income 16 State tax withheld 17 StatoPayer's state na 18 State income $ $ $ Form 1099-MISC (keep for your records) www.irs gov/Form 1099MISC Department of the Treasury - Internal Revenue Service CORRECTED (if checked) CORRECTED (if checked) PAYER'S namo, street address, city or town, state or province, country, ZIP Applicable checkbox on Form 2049 OMB No 1545-0715 Proceeds From or foreign postal code, and telephone no. D I TRADE ONLINE INVESTMENTS 2019 Barter Exchange Broker and 5621 LA HABRA PARKWAY, STE 13 Form 1099-B Transactions YOUR CITY, YS XXXXX 1a Description of property (Example: 100 sh. XYZ Co.) 816-555-XXXX 100 SHARES ALX 1b Date acquired 1c Date sold or disposed 05/05/2017 11/01/2019 PAYER'S TIN RECPENT'S TIN 1d Proceeds 1e Cost or other basis $ 2,700.00 $ 3,100.00 For Recipient 09-2014505 XXX-XX-0045 1f Accrued market discount 1g Wash sale loss disallowed $ |$ RECIPIENT'S name 2 Short-term gain or loss 3 I checked, proceeds from: BRUCE H. HARRISON Long-term gain or loss Collectibles Ordinary QOF This is important tax Street address including apt. no.) 4 Federal income tax withheld 5 I checked, noncovered information and is $ security being furnished to 1312 LOCUST STREET 6 Roported to RS: 7 If checked, loss is not allowed the IRS. If you are City or town, state or province, country, and ZP or foreign postal code required to file a based on amount in 1d Gross proceeds return, a negligence YOUR CITY, YS XXXXX Net proceeds penalty or other 8 Profit or loss) realized in 9 Unrealized profit or foss) on sanction may be Account number (see instruction) 2019 on closed contracts open contracts - 12/31/2018 imposed on you it this income is 12-34567891 $ taxable and the IRS CUSIP number FATCA fling 10 Unrealized profit or loss on 11 Aggregate profit or foss) determines that it requirement open contracts - 12/31/2019 on contracts has not been 14 State name 15 State identification no. 16 State tax withheld $ reported. 12 I checked, basis reported 13 Bartering to IRS Form 1099-B (Keep for your records) www.irs.gov/Form 1000B Department of the Treasury - Internal Revenue Service . RECIPIENTS/LENDER'S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no. REALTY MORTGAGE COMPANY 691 PLEASANT GROVE YOUR CITY, YS XXXXX XXX-555-XXXX RECIPIENTS/LENDER'S TIN PAYER'S BORROWER'S TIN 09-2014506 XXX-XX-0045 Caution: The amount shown may OMB No. 1545-1380 not be fully deductible by you. Limits based on the loan amount 2019 and the cost and value of the Mortgage secured property may apply. Also, Interest extent i was incurred by you Statement actually paid by you, and nol reimbursed by another person Form 1098 1 Mortgage interest received from payer(s)/borrower(s)" Copy B $ 8,241.64 For Payer/ 2 Outstanding mortgage 3 Mortgage origination date Borrower principal $ 125,067.00 05/04/2014 The information in boxes 1 4 Refund of overpad through 9 and 11 is important 5 Mortgage insurance interest premiums tax information and is being turnished to the IRS. If you are $ $ required to file a return, a 6 Points paid on purchase of principal residence negligence penaty or other $ sanction may be imposedon you if the IRS determines that 7 X l address of property securing mortgage is the same an underpayment of tax as PAYER'S/BORROWER'S address, the box is checked, ar results because you the address or description is entered in box 8. overstated a deduction for this mortgage interest or for 8 Address or description of property securing mortgage (see these points, reported in instructions) boxes 1 and 6: or because you didn't report the round of interest (box 4; or because you claimed a nondeductible PAYER'S/BORROWER'S name BRUCE AND LOIS HARRISON Street address including apt. no.) 1312 LOCUST STREET City or town, state or province, country, and ZIP or foreign postal code YOUR CITY, YS XXXXX 9 Number of properties securing the 10 Other mortgage RE TAX: $2,315 Account number (see instructions) 11 Mortgage acquisition dale Form 1098 Keep for your records) www.is.gov/Form 1098 Department of the Treasury - Internal Revenue Service SLOl18 Zon SLOL18 rm1095-B Health Coverage VOD OMB No 1545-7252 Department of the Try Do not attach to your tax return. Keep for your records. CORRECTED 2019 Internal Revenue S Go to www.irs.gov/Form 10958 for instructions and the latest Information Part 1 Responsible Individual 1 Name of responsable dnius-First name, rade name, last name 2 Social security number (SSR or other TN 3 Date of birth it SSN or other TN is not available) BRUCE H. HARRISON XXX-XX-0046 4 Standing apartment no 5 City or town 7 Courtyard Perforen postal code 1312 LOCUST STREET YOUR CITY YS USA XXXXX Enter letter identitying Origin of the Health Coverage (see instructions for codes B Part II Information About Certain Employer-Sponsored Coverage (see instructions) 10 Employer rano 11 Employer identification number (EN ELM CONSTRUCTION AGENCY 09-2014502 12 Shroot address ang room or su 13 City or town 14 State 15 Country and Pas forcegn portal code 6 GREENWOOD LANE YOUR CITY YS USA XXXXX Part III Issuer or Other Coverage Provider (see instructions) 16 Name 17 Employer identification number 18 Contact telephone number GENERAL INSURANCE COMPANY 09-2014507 (XXX) 562-5543 10 Great add chodno tome watero) 20 Cayor town 22 Country and ZP or for postal code 1776 TURNBULL CANYON YOUR CITY YS USA XXXXX Part IV Covered Individuals (Enter the information for each covered individual.) (a) Name of covered individu SSN other TN008 ISSN Goes Covered el Moto Testame, middle arome TN is related Jan Feb Mar Apr May Jun JU Aug Sep Oct Dec DOO X OD H. HARRISON XXX-XX-0045 NO BRUCE 24 LOIS A. HARRISON 201-00-1451 X 000000000000 o OOO OOD X 25 B. HARRISON 201-00-2451 LYLA KEVIN 26 E. HARRISON 201-00-2452 X OO DOO D D 27 O ODOO OOOOO 28 For Privacy Act and Paperwork Reduction Act Notice, se separate instructions. Cut N 00185 Form 1096-B 2016