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845 3 U.S. Individual Income Tax Declaration OMB No. 1545-0936
Fe en EET

om for Electronic Filing |

Department of the Treasury al 9 87
Internal Revenue Service For the year January 1-December 31, 1987 |

Use IRS | YoU" fitstname and initial (ifjint return, also ge spouse's name and initial Last name Your social security number
label.

Otherwise, ‘Spouse's so

please i

print or Telephone number (optional)
type. ( )

If the taxpayer’s name changed during the past 3 years due to marriage, divorce, etc., and he or she filed a Federal income tax return using
the former name, print the former name(s) in the space provided below.

First name and initial Lastname

Tax Return Information (Whole dollars only.)

1 Total income (Form 1040, line 22; Form 1040A, line 10; Form 1040EZ, line3). . . . . . wwe 1
2 Total tax (Form 1040, line 53; Form 1040A, line 20; Form 1040EZ, line9) . . 2. . 2. ww ee 2
3 Refund (Form 1040, line 63; Form 1040A, line 23; Form 1040EZ,linel0) . . . . . - | 8

GEE *CDirect Deposit of Refund (See the instructions on the back of this form.)

> |

Y | 4 Name of financial institution and, if applicable, branch a

=
Eg
52 5 Routing transit number (RTN)
a
5h
3s 6 Depositor account number
5
O85
Be 7 Type of depositor account : oO Savings OR oO Checking
83
& | 8 Sourcecode: [_] Blank check OR (J Form 1099-INT/Other
&
9 Indicate owner of depositor account (check one): __L_] Self, CO Husband, [J wite, on 1 Husband and Wife

GEME Declaration of Taxpayer

Under penalties of perjury, | declare that the amounts described in Part | above agree with the amounts shown on the corresponding lines
of my 1987 Federal income tax return given to me by my tax return preparer/transmitter, and that | have also compared the information
contained on my return with the information | provided to my preparer/transmitter. To the best of my knowledge and belief, my return and,
if applicable, the account information shown on lines 4 through 9 in Part Il above are true, correct, and complete. | consent that my return,
including this declaration and accompanying schedules and statements, be sent to the Internal Revenue Service by my tax return
transmitter and, if applicable, that my refund be directly deposited as designated in Part II above. If joint return and the refund is to be
directly deposited, this is an irrevocable appointment of the other spouse as an agent to receive the refund.

Please

Sign
Here Your signature Date ‘Spouse’s signature (if joint return, BOTH must sign)

Declaration of Preparer/Transmitter (If the transmitter did not prepare the tax return, check here. > oO y

| declare that the above taxpayer's return is based on all information of which | have knowledge and, if applicable, that | have verified that
the taxpayer's name shown on this declaration agrees with the name that appears on the proof of account. A copy of all forms and
information to be filed with the Internal Revenue Service has been provided to the taxpayer.

Paid | Date Your social security number.
1 Your Check if
Preparer’s/ signature self-employed [_]
Transmitter’s Furs pare (r) » E.I, No.
Ours if seltseTMmploye os
Use Only bnd adress ZIP code

For Paperwork Reduction Act Notice, see back of form. Form 8453 (1987)


Form 8453 (1987) Page 2

Paperwork Reduction Act Notice

We ask for this information to carry out the Internal Revenue laws of the United States. We need it to ensure that taxpayers are complying
with these laws and to allow us to figure and collect the right amount of tax. You are required to give us this information.

Declaration Control Number (DCN)

The DCN is a 14-digit number assigned to each taxpayer account. The preparer should enter the electronic filer identification number,
the appropriate sequential number, and the appropriate serial number in the boxes in the upper right corner of the form as follows:

Boxes Entry

4-8 Electronic filer identification number (EFIN) assigned by IRS

10-13 Sequential number assigned to the return by the electronic filer

14-15 Serial number (00 through 99) assigned to the return by the electronic filer

Example.— The electronic filer identification number is 12345. The sequential number is 6789. The serial number is 10. The DCN to be
entered in the boxes should be shown as 00-12345-678910-8.

Name and Social Security Number

If the taxpayer received a mailing label from us, place the label in the name area. Mark through any errors on the label and print the correct
information on the label.

If the taxpayer did not receive a label, print or type the taxpayer's name and social security number in the spaces provided on the form.
‘Name Change.—f the taxpayer's name changed during the past 3 years because of marriage, divorce, etc., and he or she filed a Federal
income tax return using the former name, print the former name(s) in the space provided on the form.

Part Il.—Direct Deposit of Refund
Complete lines 4 through 9 ONLY if the taxpayer elects to have the refund directly deposited to his or her account in a financial institution.
Line 6.—Do not include hyphens or spaces when entering the account number. If the account number is less than 17 digits, enter a zero

(0) in each of the remaining boxes. For example, if the account number is 11 digits, a zero should be entered in each of the last six boxes
provided on line 6.