What amount may the Harrisons claim for the credit for child and dependent care expenses?

$600

$1,200

$1,400

$1,440

Mark for follow up

Question 10 of 35.

What amount do the Harrisons report for "total other taxes" on Schedule 4 (Form 1040)?

$0

$89

$177

$212

Mark for follow up

Question 11 of 35.

How do the Harrisons report the sale of shares of ALX stock, reported to Bruce on Form 1099-B?

A net, short-term capital loss of $300 on Schedule D.

A net, long-term capital loss of $300 on Schedule D.

A net, short-term capital gain of $300 on Schedule D.

A net, long-term capital gain of $2,500 on Schedule D.

Mark for follow up

Question 12 of 35.

What is the amount of the Harrisons' refund?

$6,318

$6,510

$6,618

$6,865

Mark for follow up

Question 13 of 35.

What amount do the Harrisons report for total income on their federal Form 1040?

$82,400

$82,650

$82,700

$82,950

Mark for follow up

Question 14 of 35.

What amount should the Harrisons report as business income? This amount is also reported as Lois's net profit from business.

$1,250

$1,268

$1,500

$1,732

Mark for follow up

Question 15 of 35.

What amount may the Harrisons claim for the Child Tax Credit/Credit for Other Dependents?

$1,000

$2,000

$3,000

$4,000

Taxpayer Information Bruce H. Harrison Taxpayer name: Taxpayer SSN: Taxpayer DOB: Health care coverage: Spouse name: Spouse SSN: Spouse DOB: Health care coverage: Address: XXX-XX-0124 April 1, 1976 12 months through employer Lois A. Harrison 749-01-3932 March 28, 1981 12 months through spouse's employer 1312 Locust Street Salem, OR 97301 Taxpayers own their home (XXX) 555-6336 (Taxpayer); Preferred (anytime); FCC: Yes, OK to call bhharrison@net.net Contractor Newscaster Living arrangement: Cell phone: Taxpayer email: Taxpayer occupation: Spouse occupation: 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. They both wish to designate $3 to the Presidential Election Campaign Fund. Neither is blind or disabled. Neither is a student. Neither Bruce nor Lois provided their driver's license or state identification. They did not suffer any casualty losses in 2018. Bruce and Lois have no authority over a foreign account, and they did not receive a distribution from, nor were they the grantor of or transferor to, a foreign trust. They consent to the use of their tax return information for other products and services. They have not received a notice from the IRS or any state or local taxing authority within the last year. The IRS has not issued an Identity Protection ID Number for their return. Household Information Dependent name: Dependent SSN: Dependent DOB: Dependent relationship: Time in household: Gross income: Support: Health care coverage: Lyla B. Harrison 749-01-8335 July 12, 2013 Daughter 12 months SO Does not provide over half of her own support 12 months through parent's employer Dependent name: Dependent SSN: Dependent DOB: Dependent relationship: Time in household: Gross income: Support: Health care coverage: Kevin E. Harrison 749-01-9335 October 15, 2015 Son 12 months $0 Does not provide over half of his own support 12 months through parent's employer Lyla and Kevin lived with Bruce and Lois all year long and 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, 2018, was $13,093.75. 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 $7,000 ($3,500 for each child) to care for Kevin and Lyla while they worked. The center's EIN is 49-0327001. 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. Note: The decimal value from the Oregon DOR online calculator is .04. This should help when calculating Schedule OR-WFHDC. 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 $250 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. With regard to the qualified business income deduction, you may enter "0" in the corresponding fields in BlockWorks. Capital Assets Bruce was unhappy with the performance of an investment he had made in 2016. He sold the shares of stock on November 7, 2018, for fear the stock would continue its downward trend. Information relating to this sale was reported on a Form 1099-B, which Bruce brought to his appointment. This form is shown in the Information Documents section. Use only for the Oregon final test. All other learners should refer to their respective course information. 0124 number Visit the IRS website at www.irs.govlenile a Employee's social secunty number XXX-XX-0124 b Employer identification number (EIN) 49-0327872 c Employer's name, address, and ZIP code ELM CONSTRUCTION AGENCY Safe, accurate, OMB No 1545-0008 FAST! Use 1 Wages, tips other compensation 37,950.00 3 Social Soounty wages 39,950.00 6 Medicare wages and tips 39,950.00 7 Social Security tips 2 Federal income tax withheld 3,701.72 4 social security tax withhold 2,476.90 6 Medicare tar withhold 579.28 8 Allocated tips 6 GREENWOOD LANE YOUR CITY, YS XXXXX d Control number 9 Verification code 10 Dependent care benefits e Employee's first name and initial Last name Suff. 11 Nonquaified plans BRUCE H. HARRISON 12a See instructions for box 12 DD 14,685.00 12b D 2,000.00 13 Statutory Slove Retirement Third party say 1312 LOCUST STREET 14 Other YOUR CITY, YS XXXXX OOOOOO NIN 1 Employee's address and ZIP code 15 State Employer's state ID number YS 490327872A 18 Local wages, tips, eto. 19 Local income tax 2 0 Locality name 16 State wages, tips eto. 37,950.00 17 State income tax 2,587.25 Department of the Treasury-Internal Revenue Service Wage and Tax Form Statement Copy B-To Be Filed With Employee's FEDERAL Tax Return This information is being furnished to the Internal Revenue Service. 2018 OMB No 1545-0008 Safe, accurate, FAST! Use r ser file Visit the IRS website at www.rs goverila 2 a Employee's social secunty number 749-01-3932 b Employer identification number (EIN) 49-0327873 c Employer's name, addross, and ZIP code LOCAL NEWS NETWORK 1 Wages, tips, other compensation 36,500.00 3 Social Security wagos 36,500.00 6 Medicare wages and tips 36,500.00 7 Social secunty tips Federal income tax withheld 4,428.00 4 Social security tax withhold 2,263.00 6 Medicare tar withhold 529.25 8 Allocated tips 112 NORTHERN STREET YOUR CITY, YS XXXXX d Control number 9 Verification code 10 Dependent care benefits e Employee's first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12 13 Statutory Segove Retirement AS This party sck pay 124 LOIS A. HARRISON 1312 LOCUST STREET 14 Other YOUR CITY, YS XXXXX f Employee's address and ZIP code 15 State Employer's state ID number YS 490327 873A 18 Local wages, tips, oto 1 9 Local income tax 20 Locality name 16 Sate wages, tips eto 36,500.00 17 State income tax 2,175.00 Department of the Treasury-Internal Revenue Service Wage and Tax Form Statement Copy B-To Be Filed With Employee's FEDERAL Tax Return This information is being furnished to the Internal Revenue Service 2018 CORRECTED (if checked) PAYER'S name, street address, city or town, state or province, country, ZIP 1 Rents or foreign postal code, and telephone no. OMB No. 1545-0115 NEIGHBORHOOD COMMUNITY CENTER 2018 Miscellaneous Income 2 Royalties 1511 CHERRY STREET Form 1099-MISC 4 Federal income tax withheld YOUR CITY, YS XXXXX 3 Other income Copy B For Recipient 6 Fishing boat proceeds 6 Medical and health care payments PAYER'S TIN 49-0327874 RECIPIENTS TIN 749-01-3932 RECIPIENT S name 7 Nonemployee compensation 8 Substitute payments in lieu of dividends or interest LOIS A. HARRISON Street address (including apt. no.) $ 10 Crop insurance proceeds 1312 LOCUST STREET $ 1,500.00 9 Payer made direct sales of $5,000 or more of consumer products to a buyer recipient for resale This is important tax information and is being furnished to the IRS. If you are required to file a return, a negligence penalty or other sanction may be imposed on you it this income is taxable and the IRS determines that it has not been reported. City or town, state or province, country, and ZIP or foreign postal code YOUR CITY, YS XXXXX Account number (see instructions) FATCA filing requirement 13 Excess golden parachute payments 14 Gross proceeds paid to an attorney 15a Section 409A deferrals 156 Section 409A income 16 State tax withheld 17 State/Payer's state no. 18 State income Form 1099-MISC (keep for your records) www.irs.gov/Form1099MISC Department of the Treasury - Internal Revenue Service CORRECTED (if checked) PAYER'S name, street address, city or town, state or province, country, ZIP Applicable check box on Form 8949 or foreign postal code, and telephone no. OMB No. 1545-0715 Proceeds From Broker and Barter Exchange Transactions I TRADE ONLINE INVESTMENTS 5621 LA HABRA PARKWAY, STE 13 YOUR CITY, YS XXXXX Form 1099-B 1a Description of property (Example: 100 sh.XYZ Co.) 30 SHARES ALX 1b Date acquired 10 Date sold or disposed 05/03/2016 11/07/2018 1d Proceeds 1e Cost or other basis $ 2,500.00 $ 2,800.00 1f Accrued market discount 1g Wash sale loss disallowed PAYER'S TIN RECIPIENT'S TIN Copy B For Recipient 49-0327007 XXX-XX-0124 RECIPIENT'S name BRUCE H. HARRISON 2 Short-term gain or loss 3 if checked, basis reported to IRS Long-term gain or loss X Ordinary X 4 Federal income tax withheld 5 If checked, noncovered security Street address (including apt. no.) 1312 LOCUST STREET 7 If checked, loss is not allowed based on amount in 1d City or town, state or province, country, and ZIP or foreign postal code 6 Reported to IRS Gross proceeds Net proceeds 8 Profit or loss) realized in 2018 on closed contracts YOUR CITY, YS XXXXX This is important tax information and is being furnished to the IRS. If you are required to file a return, a negligence penalty or other sanction may be imposed on you if this income is taxable and the IRS determines that it has not been reported. 9 Unrealized profit or loss) on open contracts-12/31/2017 Account number (see instructions) 12-34567891 CUSIP number FATCA filing requirement 10 Unrealized profit or loss) on open contracts-12/31/2018 11 Aggregate profit or loss) on contracts 14 State name 15 State identification no. 16 State tax withheld $ 12 Check if proceeds from collectibles 13 Bartering $ Department of the Treasury - Internal Revenue Service Form 1099-B (Keep for your records) www.irs.gov/Form 10998 SL0118 OMB No 1545-22:52 1095-B VOD CORRECTED 2018 Health Coverage Department of the Treasury Do not attach to your tax return. Keep for your records. Internal Revenue Serve Go to www.in.gov/Fom 10058 for instructions and the latest information Partl Responsible Individual 1 Name of responibile individual Forsta d ena, laste 2 Socie ty urbe (SSN) BRUCE HARRISON XXX-XX-0124 4 Street address induding apartment no) 5 City or town 6 State or province 1312 LOCUST STREET YOUR CITY other TN3 Date of SSN or other TN is not available n postal code Country and ZIP o USA XXXXX YS * Enter letter identifying Origin of the Health Coverage see instructions for codes .. Part II Information About Certain Employer-Sponsored Coverage See instructions), 10 Employer namo 11 Employer identication number EN ELM CONSTRUCTION AGENCY 49-0327872 12 Shoot address including room o utono 13 City or town 14 Stop 15 Country and ZIP or foreign portal code 6 GREENWOOD LANE YOUR CITY YS USA XXX X X Part III Issuer or Other Coverage Provider See instructions) 16 me 17 Employer identification number 18 Contact telephone number GENERAL INSURANCE COMPANY 49-0327870 (XXX) 552-5543 10 Set adres including room outro) 20 Clyor own 21 Stop 22 Country and ZP a foreign postal code 456 OVERLOOK AVE YOUR CITY YS USA XXXXX Part IV Covered Individuals (Enter the information for each covered individual.) Name of covered individu () SSN och TIN (0)DOB ISSN oth (d) Cover 1 Months of Festa dome This 12 monde Jan Feb Mar Apr May Jun Ju Aug Sep Oct Nov Dec BRUCE 23 2. HARRISON XXX-XX-0124 LOIS A. HARRISON 749-01-3932 24 OOOO LYLA B. HARRISON - 000000000000 000000000000 DODDDDDD0000 000000000000 DDDDD00000000 0000000000000 749-01-8335 KEVIN E. HARRISON 749-01-9335 For Privacy Act and Paperwork Reduction Act Notice, se separate instructions CN07B Form 1095-B 2018) Taxpayer Information Bruce H. Harrison Taxpayer name: Taxpayer SSN: Taxpayer DOB: Health care coverage: Spouse name: Spouse SSN: Spouse DOB: Health care coverage: Address: XXX-XX-0124 April 1, 1976 12 months through employer Lois A. Harrison 749-01-3932 March 28, 1981 12 months through spouse's employer 1312 Locust Street Salem, OR 97301 Taxpayers own their home (XXX) 555-6336 (Taxpayer); Preferred (anytime); FCC: Yes, OK to call bhharrison@net.net Contractor Newscaster Living arrangement: Cell phone: Taxpayer email: Taxpayer occupation: Spouse occupation: 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. They both wish to designate $3 to the Presidential Election Campaign Fund. Neither is blind or disabled. Neither is a student. Neither Bruce nor Lois provided their driver's license or state identification. They did not suffer any casualty losses in 2018. Bruce and Lois have no authority over a foreign account, and they did not receive a distribution from, nor were they the grantor of or transferor to, a foreign trust. They consent to the use of their tax return information for other products and services. They have not received a notice from the IRS or any state or local taxing authority within the last year. The IRS has not issued an Identity Protection ID Number for their return. Household Information Dependent name: Dependent SSN: Dependent DOB: Dependent relationship: Time in household: Gross income: Support: Health care coverage: Lyla B. Harrison 749-01-8335 July 12, 2013 Daughter 12 months SO Does not provide over half of her own support 12 months through parent's employer Dependent name: Dependent SSN: Dependent DOB: Dependent relationship: Time in household: Gross income: Support: Health care coverage: Kevin E. Harrison 749-01-9335 October 15, 2015 Son 12 months $0 Does not provide over half of his own support 12 months through parent's employer Lyla and Kevin lived with Bruce and Lois all year long and 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, 2018, was $13,093.75. 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 $7,000 ($3,500 for each child) to care for Kevin and Lyla while they worked. The center's EIN is 49-0327001. 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. Note: The decimal value from the Oregon DOR online calculator is .04. This should help when calculating Schedule OR-WFHDC. 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 $250 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. With regard to the qualified business income deduction, you may enter "0" in the corresponding fields in BlockWorks. Capital Assets Bruce was unhappy with the performance of an investment he had made in 2016. He sold the shares of stock on November 7, 2018, for fear the stock would continue its downward trend. Information relating to this sale was reported on a Form 1099-B, which Bruce brought to his appointment. This form is shown in the Information Documents section. Use only for the Oregon final test. All other learners should refer to their respective course information. 0124 number Visit the IRS website at www.irs.govlenile a Employee's social secunty number XXX-XX-0124 b Employer identification number (EIN) 49-0327872 c Employer's name, address, and ZIP code ELM CONSTRUCTION AGENCY Safe, accurate, OMB No 1545-0008 FAST! Use 1 Wages, tips other compensation 37,950.00 3 Social Soounty wages 39,950.00 6 Medicare wages and tips 39,950.00 7 Social Security tips 2 Federal income tax withheld 3,701.72 4 social security tax withhold 2,476.90 6 Medicare tar withhold 579.28 8 Allocated tips 6 GREENWOOD LANE YOUR CITY, YS XXXXX d Control number 9 Verification code 10 Dependent care benefits e Employee's first name and initial Last name Suff. 11 Nonquaified plans BRUCE H. HARRISON 12a See instructions for box 12 DD 14,685.00 12b D 2,000.00 13 Statutory Slove Retirement Third party say 1312 LOCUST STREET 14 Other YOUR CITY, YS XXXXX OOOOOO NIN 1 Employee's address and ZIP code 15 State Employer's state ID number YS 490327872A 18 Local wages, tips, eto. 19 Local income tax 2 0 Locality name 16 State wages, tips eto. 37,950.00 17 State income tax 2,587.25 Department of the Treasury-Internal Revenue Service Wage and Tax Form Statement Copy B-To Be Filed With Employee's FEDERAL Tax Return This information is being furnished to the Internal Revenue Service. 2018 OMB No 1545-0008 Safe, accurate, FAST! Use r ser file Visit the IRS website at www.rs goverila 2 a Employee's social secunty number 749-01-3932 b Employer identification number (EIN) 49-0327873 c Employer's name, addross, and ZIP code LOCAL NEWS NETWORK 1 Wages, tips, other compensation 36,500.00 3 Social Security wagos 36,500.00 6 Medicare wages and tips 36,500.00 7 Social secunty tips Federal income tax withheld 4,428.00 4 Social security tax withhold 2,263.00 6 Medicare tar withhold 529.25 8 Allocated tips 112 NORTHERN STREET YOUR CITY, YS XXXXX d Control number 9 Verification code 10 Dependent care benefits e Employee's first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12 13 Statutory Segove Retirement AS This party sck pay 124 LOIS A. HARRISON 1312 LOCUST STREET 14 Other YOUR CITY, YS XXXXX f Employee's address and ZIP code 15 State Employer's state ID number YS 490327 873A 18 Local wages, tips, oto 1 9 Local income tax 20 Locality name 16 Sate wages, tips eto 36,500.00 17 State income tax 2,175.00 Department of the Treasury-Internal Revenue Service Wage and Tax Form Statement Copy B-To Be Filed With Employee's FEDERAL Tax Return This information is being furnished to the Internal Revenue Service 2018 CORRECTED (if checked) PAYER'S name, street address, city or town, state or province, country, ZIP 1 Rents or foreign postal code, and telephone no. OMB No. 1545-0115 NEIGHBORHOOD COMMUNITY CENTER 2018 Miscellaneous Income 2 Royalties 1511 CHERRY STREET Form 1099-MISC 4 Federal income tax withheld YOUR CITY, YS XXXXX 3 Other income Copy B For Recipient 6 Fishing boat proceeds 6 Medical and health care payments PAYER'S TIN 49-0327874 RECIPIENTS TIN 749-01-3932 RECIPIENT S name 7 Nonemployee compensation 8 Substitute payments in lieu of dividends or interest LOIS A. HARRISON Street address (including apt. no.) $ 10 Crop insurance proceeds 1312 LOCUST STREET $ 1,500.00 9 Payer made direct sales of $5,000 or more of consumer products to a buyer recipient for resale This is important tax information and is being furnished to the IRS. If you are required to file a return, a negligence penalty or other sanction may be imposed on you it this income is taxable and the IRS determines that it has not been reported. City or town, state or province, country, and ZIP or foreign postal code YOUR CITY, YS XXXXX Account number (see instructions) FATCA filing requirement 13 Excess golden parachute payments 14 Gross proceeds paid to an attorney 15a Section 409A deferrals 156 Section 409A income 16 State tax withheld 17 State/Payer's state no. 18 State income Form 1099-MISC (keep for your records) www.irs.gov/Form1099MISC Department of the Treasury - Internal Revenue Service CORRECTED (if checked) PAYER'S name, street address, city or town, state or province, country, ZIP Applicable check box on Form 8949 or foreign postal code, and telephone no. OMB No. 1545-0715 Proceeds From Broker and Barter Exchange Transactions I TRADE ONLINE INVESTMENTS 5621 LA HABRA PARKWAY, STE 13 YOUR CITY, YS XXXXX Form 1099-B 1a Description of property (Example: 100 sh.XYZ Co.) 30 SHARES ALX 1b Date acquired 10 Date sold or disposed 05/03/2016 11/07/2018 1d Proceeds 1e Cost or other basis $ 2,500.00 $ 2,800.00 1f Accrued market discount 1g Wash sale loss disallowed PAYER'S TIN RECIPIENT'S TIN Copy B For Recipient 49-0327007 XXX-XX-0124 RECIPIENT'S name BRUCE H. HARRISON 2 Short-term gain or loss 3 if checked, basis reported to IRS Long-term gain or loss X Ordinary X 4 Federal income tax withheld 5 If checked, noncovered security Street address (including apt. no.) 1312 LOCUST STREET 7 If checked, loss is not allowed based on amount in 1d City or town, state or province, country, and ZIP or foreign postal code 6 Reported to IRS Gross proceeds Net proceeds 8 Profit or loss) realized in 2018 on closed contracts YOUR CITY, YS XXXXX This is important tax information and is being furnished to the IRS. If you are required to file a return, a negligence penalty or other sanction may be imposed on you if this income is taxable and the IRS determines that it has not been reported. 9 Unrealized profit or loss) on open contracts-12/31/2017 Account number (see instructions) 12-34567891 CUSIP number FATCA filing requirement 10 Unrealized profit or loss) on open contracts-12/31/2018 11 Aggregate profit or loss) on contracts 14 State name 15 State identification no. 16 State tax withheld $ 12 Check if proceeds from collectibles 13 Bartering $ Department of the Treasury - Internal Revenue Service Form 1099-B (Keep for your records) www.irs.gov/Form 10998 SL0118 OMB No 1545-22:52 1095-B VOD CORRECTED 2018 Health Coverage Department of the Treasury Do not attach to your tax return. Keep for your records. Internal Revenue Serve Go to www.in.gov/Fom 10058 for instructions and the latest information Partl Responsible Individual 1 Name of responibile individual Forsta d ena, laste 2 Socie ty urbe (SSN) BRUCE HARRISON XXX-XX-0124 4 Street address induding apartment no) 5 City or town 6 State or province 1312 LOCUST STREET YOUR CITY other TN3 Date of SSN or other TN is not available n postal code Country and ZIP o USA XXXXX YS * Enter letter identifying Origin of the Health Coverage see instructions for codes .. Part II Information About Certain Employer-Sponsored Coverage See instructions), 10 Employer namo 11 Employer identication number EN ELM CONSTRUCTION AGENCY 49-0327872 12 Shoot address including room o utono 13 City or town 14 Stop 15 Country and ZIP or foreign portal code 6 GREENWOOD LANE YOUR CITY YS USA XXX X X Part III Issuer or Other Coverage Provider See instructions) 16 me 17 Employer identification number 18 Contact telephone number GENERAL INSURANCE COMPANY 49-0327870 (XXX) 552-5543 10 Set adres including room outro) 20 Clyor own 21 Stop 22 Country and ZP a foreign postal code 456 OVERLOOK AVE YOUR CITY YS USA XXXXX Part IV Covered Individuals (Enter the information for each covered individual.) Name of covered individu () SSN och TIN (0)DOB ISSN oth (d) Cover 1 Months of Festa dome This 12 monde Jan Feb Mar Apr May Jun Ju Aug Sep Oct Nov Dec BRUCE 23 2. HARRISON XXX-XX-0124 LOIS A. HARRISON 749-01-3932 24 OOOO LYLA B. HARRISON - 000000000000 000000000000 DODDDDDD0000 000000000000 DDDDD00000000 0000000000000 749-01-8335 KEVIN E. HARRISON 749-01-9335 For Privacy Act and Paperwork Reduction Act Notice, se separate instructions CN07B Form 1095-B 2018)