Filer legal name / secure TIN reference:
Reporting year / original due date / source:
Underlying return type and filing method:
Initial or additional request:
Applicable line 7 criterion and evidence, if required:
Contact / correspondence address:
Multiple-filer attachment and count:
Current submission route / instructions edition:
Signature authority, if required:
Reviewer / final version / submission evidence:
Recipient and state obligations tracked separately: