(See Instructions on back)

IRS Use Only

OMB No.

1545-0367 

Form 4804

 (Rev. May 2002)

Department of the Treasury – Internal Revenue Service 

Transmittal of Information Returns 

Reported Magnetically

Please type or print in BLACK ink

(Use a separate Form 4804 for each file.)

1. Type of file represented by this transmittal 

Original

Replacement 

Test

Correction

2. Tax year for

which media is

submitted 

3. Transmitter Control Code (TCC) (Required) 

 

 4. Name of transmitter (Owner of TCC)

5. Name/address of company and name/title of person who should receive correspondence on problem files

(should be the same information as in 'T' record)

Company Name 

Address ____________________________________________________________________

City ____________________________________ State ____________ Zip _______________

Contact Person ______________________ Telephone Number (_____) ________________ 

E-mail Address ______________________________________________________________

6. Forms 1098, 1099, 5498, 

W-2G Combined total of payee

'B' records 

7. Form 1042-S 

Total number of 'Q'

records 

8. Form 8027 Total number of

establishment(s) reported 

9. Transmitter in-house 

media number(s)

Affidavit 

Under penalties of perjury, I declare that I have examined this transmittal, including accompanying

documents, and, to the best of my knowledge and belief, it is correct and complete. 

(Normally, the payer must sign the affidavit above. The authorized agent of the payer may sign if all 

conditions are met as stated on the back.) 

S IRS Use Only IGNATURE (Required)

Title Date 

Catalog Number 27210I Form 4804 (Rev. 5-2002) 
Form 4804 (Rev. 5-2002) 

General Instructions 

Paperwork Reduction Act Notice. We ask for the information on 

these forms to carry out the Internal Revenue Laws of the United 

States. You are not required to provide the information requested 

on a form that is subject to the Paperwork Reduction Act unless 

the form displays a valid OMB control number. Books or records 

relating to a form must be retained as long as their contents may 

become material in the administration of any Internal Revenue 

law. Generally, tax returns and return information are confidential, 

as required by Code section 6103. 

 The time needed to provide this information would vary 

depending on individual circumstances. The estimated average 

time is: 

Preparing Form 4804 . . . . . . . . . . . . . . . . . . . . . . . 15 min. 

 If you have comments concerning the accuracy of these time 

estimates or suggestions for making this form simpler, we would 

be happy to hear from you. You can write to the Tax Forms 

Committee, Western Area Distribution Center, Rancho Cordova, 

CA 95743-0001. 

DO NOT SEND THE FORMS TO THIS OFFICE. Instead, see the 

instructions below on where to file. When completing this form, 

please type or print clearly in BLACK ink. 

Purpose of Form. Use Form 4804 when submitting the following 

types of information returns magnetically: Form 1098, 1099, 

5498, W-2G, 1042-S, and 8027. You must include Form 4804 with 

all magnetic media you submit to the Internal Revenue Service. 

NOTE: A separate Form 4804 must be submitted for each file. 

Specific Instructions

Block 1

Indicate whether the data in this shipment is an original, 

correction, replacement or test file by checking the 

appropriate box. Check ‘Replacement’ only if you are 

sending media in response to a specific request from 

IRS/MCC and you have a Form 9267 attached. 

Definitions 

Correction: A correction is an information return submitted by 

the payer to correct erroneous information previously sent to and 

processed by IRS/MCC. 

Replacement: A replacement is an information return file sent by 

the filer at the request of IRS/MCC because of errors 

encountered while processing the filer's original return. Your 

replacement file may be submitted electronically even if the 

original file was sent on magnetic media. 

Block 2 

Indicate the tax year for which media is being submitted.

Block 3

Enter the five-character alpha/numeric Transmitter Control Code 

assigned by IRS. TCCs for Form 1042-S filing begin with the 

numbers 22. TCCs for Form 8027 filing begin with the numbers 21.

Block 4

Enter the name of the transmitter. (Reference Affidavit 

Requirements below.)

Block 5

Enter the name and address of the company, along with the 

name/title of the person to whom correspondence concerning 

problem media in need of replacement should be sent. This 

information should match the information that appears in the 

Transmitter 'T' Record in your file. Please include an email address 

if available

NOTE: IRS no longer returns media in need of replacement. 

Block 6,7,8 

Use only the boxes appropriate to the forms you are reporting. A 

separate Form 4804 is required for the information returns in box 6, 

1042-S Forms in box 7, and 8027 Forms in box 8. 

Block 6 

Enter the combined number of all payee 'B' records on the media 

sent with this Form 4804. 

Block 7 

If reporting Form 1042-S, enter the total number Recipient ‘Q’ 

records. 

Block 8

If reporting Form 8027, enter the number of establishments 

reported. 

Block 9

If your organization uses an in-house numbering system to identify 

media, indicate the media number(s) in the appropriate block. 

Mailing Address:

Send your media with transmittal Form(s) 4804 to the address 

below: 

 IRS, Martinsburg Computing Center 

 Information Reporting Program 

 230 Murall Drive 

 Kearneysville, WV 25430 

NOTE: Form 4802, Transmittal of Information Returns Reported 

Magnetically/Electronically (Continuation) is obsolete.

Affidavit Requirement 

A transmitter, service bureau, paying agent, or disbursing agent (all hereafter referred to as “agent”) may sign Form 

4804 on behalf of the payer (or other person required to file), if the conditions in items 1 and 2 are met: 

1. The agent has the authority to sign the form under an agency agreement (oral, written, or implied) that is valid 

under state law. 

2. The agent signs the form and adds the caption “For: (Name of payer or other person required to file)”. 

he authorized agent’s signing of the affidavit on the payer’s behalf does not relieve the payer of the responsibility 

for filing a correct, complete, and timely Form 4804, with attachments, and will not relieve the payer of any penalties 

for not complying with those requirements.