Only submit this form if you received a letter from the IRS requesting that you complete and submit this form.
Instructions: Describe the amount you reported as “Other Income” on your federal tax return by providing the following information. Print and sign your name and provide a day and evening number in the spaces provided at the bottom of this form. Mail the completed form using the envelope. Important! The amounts on this form should total the amount reported as “Other Income” on your federal tax return.