Free Form 4804 (Rev. 5-2002) - Federal

(See Instructions on back)

Department of the Treasury ­ Internal Revenue Service

IRS Use Only

Form 4804
(Rev. May 2002)

Transmittal of Information Returns Reported Magnetically
Please type or print in BLACK ink (Use a separate Form 4804 for each file.)

OMB No. 1545-0367

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.)

SIGNATURE (Required)

IRS Use Only

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 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 Requirements below.) the transmitter. (Reference Affidavit

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.

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.

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.