April 1, 2022 Sandra: Anderson Department of Treasury - Remittance office, RM 3414 1500 Pennsylvania Ave, NW Washington, DC 20220 202-622-2000 To whom this my concern: Enclosed is my assessment and accounting records for an American Express Account. Included in this package are the following: 1) 2021 W4-Employee Withholding Certificate 2) Statements for American Express Account form January 2021 — December 2021 3) 2021 Form 1040v 4) 2021 1040-U.S. individual income Tax Return ‘These forms are all prepared in good faith as it is my intention to be in voluntary compliance with the IRS and its Internal Revenue Code. If there is another way you would prefer me to complete and submit this information, please let me know. If there are any errors, please inform me as to what they are so 1 can make the appropriate corrections. ‘Thanks for your attention and assistance. Kind Regards, Completed im Sead Raith Qruen Lor pekent rights CLiMnorizedk Repre sentutive: “By: Sandia. s Prokersar, Benel) AN Right Cererved B-4OR 1a oyEmployee’s Withholding Certificate >> Complete Form W-4 80 that your employer can withhold the correct federal Income tax from your P8Y- 2021 > Give Form W-4 to your employer. > Your withholding le subject to roview by the IRS. (© Lingle or Marea fing seperately C1] Married fling jointly or Qualitying widow(er) [Clea thal Cock ni y0/r raid wn pay mare than a he ato Kenn ua home or youre anda using vil) ‘Complete Stops 2-4 ONLY i they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, when to use the estimator at www.rs.gov/W4App, and privacy. In furtherance of my intending to be in voluntary compliance withthe Internal Revenue Code, | present this. good tah stimte and satoment of winelé creat fansered to the arfree Th omy good tah effort if there is another way you would ie me to do it please inform me. If there are any errors please inform me and or make the necessary corrections, ‘Statements for closing dates January 22, 2021 - through December 23,2021 Statement Closing Date 1/22/21 = $0.00: 2/19/21 = $754.74 (09/29/21 = $703.14 : 05/29/21 = $25.25 : 06/22/21 = $2209.27 o7re3i2: 1507.11 : 08/29/21 = $2956.15 : 00/22/21 = $848.17 : 10/22/21 = $1187.55 : 11/22/21 = $436.51 : 12/29/21 = $2902.86 TOTAL = 12,928.75 OR $12,930 Al Statements attached. Please see cover letter to process refund. (©) Extra withholding. Enter any additional tax you want withheld each pay period ~ [ates EXEMPT Shop 6 under patos of pen, |decare tha is crtcat, ote bet of my knowledge and bole, tue, caret and comple Hore ; : &4Pron 1, 2020 ) phrase or nt alan you OOF) ao layers | Enpoyere name and aero Faget] epoye en Ene | Areran Egress Co crncomace | Smplye ntitaton Rw ore NY 10288 January, 2021 | 13.4922950 Far Pian hat ana Paperwork Reton ht Woe, 98 page 3 ‘GaN 102200) Form Wo Goan,2024 Form 1040-V §znines srr 2021 Form 1040-V {ii scetteens seve What Is Form 1040-V? {t's a statement you send with your check or money order for any balance due on the "Amount you owe! line of your 2021 Form 1040, 1040-SR, or 1040-NR, Consider Making Your Tax Payment Electronically—it's Easy You can make electronic payments online, by phone, or from a. mobile device. Paying electronically is safe and secure. When You schedule your payment, you wil recalve immodia Confirmation from the IRS, Go to www..irs.gov/Payments to see all your electronic payment options. How To Fill in Form 1040-V Line 1. Enter your social security number (SSN). {you are filing a joint return, enter the SSN shown frst on your return. LLine 2. if you are fing a joint return, enter the SSN shown ‘second on your return. Line 3. Enter the amount you are paying by check or money Gres. paying online at wa.irs-gov!Payments, don't complete is form. Line 4, Enter your name(s) and address exactly as shown on. ‘your return. Please print clearly. How To Prepare Your Payment + Make your check oF money order payable to “United States “Treasury.” Don’t send cash. if you want to pay in cash, in person, see Pay by cash, ate. + Make sure your name and address appear on your check or money order. « Enter your daytime phone number and your SSN on your ‘heck of money order. Ifyou have an Individual Taxpayer {dontiication Number (TIN), enter it wherever your SSN is requested If you ae fling joint retum, enter the SSN shown {rst on your retum, Also, enter “2021 Form o40,"2021 Form {Y0u0-SH." or "2021 Form 1040-NR,”" whichever is appropriate. ‘To help us process your payment, enter the amount onthe fmt side of your check Ike this § 200.30 Don't use dashes or lines (for example, don't enter *§ XXX—" oF *$ X00 "Via". GaN. 20766 §1040-V apart te Tay ‘raheem ‘Y Detach Here and Mai! With Your Payment and Return ¥ Payment Voucher > Donot staple or attach this Voucher to your payment or return. > Go to www.irs.gov/Payments for payment options and information. a Tolle to taxpayers presenting checks. When you provide check as payment, you authorize us either to Use inform om from your check to make a onetime electronic fund tranetey OO your account oo process the payment as a check tansacrer {Winen we use information from your chack to make an electron! fund transfer, funds may be withdrawn trom your account ag, soon as the same day we receive your payment, and You tec our check Back fom your franca nstiuon, No checks of $100 million or more accepted. The IRS can’ accept a single check (including a cashier's check) for amourts {of $100,000,000 ($100 milion) or more. you are sending $100 illon or more by check, you will need to spread the payments jet two or more checks, with each check made out for an ‘amount less than $100 milion. ‘cash, This is an in-person payment option for individuals reiGed ugh eal pres wi a maxomum of $1,000 per day per transaction. To make a cash payment, you must first be Feaistered online at www officialpayments.comm/fed, our Official Payment provider. How To Send in Your 2021 Tax Return, Payment, and Form 1040-V ‘Don't staple or otherwise attach your payment or Form 1040-V ‘to your return or to each other. Instead, just put them loose in the envelope. ‘= Mail your 2021 tax return, payment, and Form 1040-V to the ‘address shown on the back that appiies to you. How To Pay Electronically Pay Online Paying online is convenient, secure, and helps make sure we get your payments on time. You can pay using elther of the following ‘lectronic payment To pay your taxes online or for more information, go to www.irs.gov/Payments IRS Direct Pay Pay your taxes directly from your checki 10 cost to you, You receive instant payment has been made, and 0 20 days in advance, Debit or Credit Card ‘The IRS doesn't charge a foe for this service; the card processors do, The authorized card processors and their phone ‘umbers are all online at www.irs.gov/Paymants, ing or savings account at that your you can schedule your payment up Form TO40-V aan, (OMB No. 1545-0074 2021 1 Your scl ster ruber SSN) ating sou owns anya | "on you rtm ‘2ifajointran, SSN ahown cond 3 Amount you we paving by check or et 3 |Sonan endosen 1B [ iran retum, spouse's fist name and middie initial ‘Last name : Eh eensam areas Ce O lememe eilccae r TT Taos nn For Paperwork Reduction Act Notes, see your tax retum insructons, ‘Gat No 2007562024 | vere 15474] remem onntem acer te widow“er) (OM) Filing Status (2/sngle C] Maric ng ity] Mared fing separately (HFS) [Heed household HOH) [] Qusli¥ing one yeu checked the MES box ener th nae of your spouse you checked the HOH or QW box, enter the cts name tne porsonis chil but nt your dependent a ‘Your first name and middle intial ‘Last name a Sana Anderson Wt rm apo st ae rd me Tastee rT Tre ages ar and aad you hws «PL. bx soaks Tein, | Presidential Eton Caalon Check here if you, or our .. 30 fling Joint, want $3 ‘ity ow, Tyee frig dss, abo comple spaces ow. Tae FP cade Togo to this fund. Checking @ Carlsbad ca 92008 _| box below wil not change Fork ware c arate arson pot ide |Your ax or refund, ie county wean prov any ee ‘At any time during 2021, did you receve, sel, exchange, or otherwise depose of any fancial interest in any vitual curency? _ C]¥es_ LINO ‘Standard _ Someone can claim: (] You as a dependent LJ Your spouse as a dependent Deduction (1) spouse iterizes on a separate ratum or you were a dual-status allon ‘Age’Biindness You: C] Were bom before January 2, 1957 _C] Aebiind Spouse: [1] Was bom before January2, 1957_C] Is bind Dependents (so instructions: (@)Scciesecurty | (@)Relatonsip | (4) i qualifies for (ne ntructons): Htmore (1 Fst nae Lastname tuber ‘you ri tax erat _ | Greate other dependents than four T a oO dependents, a a ‘60 nstructions ‘and check TT a oO rere oO o T_ Wages, salaries, tps, oto. AachFom@W2. a ‘aebe 2a Tax-exemptinterest . . Es bb Taxable interest... 2b fenires, 38, Qualifed dividends. 3a bb Ordinary dhidends ss. ‘ab 4a IRAdstibutions . . . . [4a bb Taxableamount.2 2.) [ap ‘Sa Pensions and annuities. . [6a bb Taxableamount. . . Sb. ‘88 Social securty benefits. [6a b Taxabloamount. - [ob 7. Capital gain or Joss). Attach Schedule Drrequied. Wet required, checkhere. . . . & OJ [7 8 Other income trom Schedule t,me 10... midistie tikes gets Add ines 1, 2b, 8, 4, 5b, 6, 7, and 8, Tis is yourtotalincome > [oe 10 Adjustments to income from Schedule 1,ine26.. abies am . De Ls1__ subtract ine 10 from ine 9. Tis in your austed grove come | > Ge “ta ‘Standard deduction or itemized deductions {rom Schedule A)... | 120 7 Chaat cones yout te snc ein net [1 ; @ Addiines 12aand 12. é é Tra [sae 13. Qualified business Income deduction fom Form 8995 or Form 8905-4. : Dos 44 Add ines 12¢ and 13 2 1“ 48 Taxable Income, Subtract ne 14 from ne 11. 260 ress, enter -O- nas tos Ferm 1040 goa')Form 1040 021) = 2021 eatmated tx payments snd arcu app from 2020 tu ss s+ ‘qustyrg chs, 27a Eamed income credit E10)... zie eee Gh tre you re bor ar san 1 1988 ad bare r » w Tex tes inter). Che ay tom For 1 6814 ane 30 17 Amount fom Schedule2,lneS 5 ss + - sone 18 Addiines 18and17 w Net ino si pres am Ste 20 Amount from Schedule S,lineB . . ee irr ‘Add ines 19 and 20... ‘ eee a 22 Subtract ne 21 Fomine 1811200 orlss enter-O- sss ss 2 Ofer ae nang seemplonent ww. rom Stade 2, he 21 5 ™ 8 ‘Add tines 22 ond 23, This syourtotaltax 2. 2 2 ee et Federal income tax withneld from: fe FomW2 ee es pM Form(s) 1099... wales sade aioe [oe © Obertoms beinmctend) «ss EBs a Addiines 26athrough 250... 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