Shown is Form 3245. Some fields are filled in as follows: SSN/TIN: 000-00-0961Return Period: 20XX12MFT: 30Name: Theresa HarmonSchedule Date: Blank (Under Cancellation Column)Date Received: 011620XX (Under Repayment Column)TC: 841 (Under Cancellation Column)Amt. of check: Blank (Under Cancellation Column)TC: 720 (Under Repayment Column)Amt. of check: 100.00 (Under Repayment Column)TC: 772 (Under Repayment Column)Interest: Blank (Under Repayment Column)Check Number: BlankDate: 020420XXSchedule Number: BlankPrepared by (initials): TCRemarks: To partially repay Erroneous Refund 20XX-45-2005