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Income: type and amount. If "None (or less than $201)" is checked, no other entry is needed in Block C for that item.

reporting period

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Туре

None (or less than $1.001)

$15,001-$50,000 $1,001-$15,000

000'001s 100'09S

$100,001 - $250,000

$500,001 - $1,000,000

$250,001-$500,000

Over $1,200,000 Dividends

Rent and Royalties

Excepted Investment Pund

Capital Gains

Excepted Trust

Qualified Trust

Interest

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X

X

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Income: type and amount. If "None (or less than $201)" is checked, no other entry is needed in Block C for that item.

Type

BLOCK C

Amount

None (or less than $1,001)

$15,001-$50,000

$100,001 - $250,000 $50,001-$100,000

$1,001-$15,000

$500,001 - $1,000,000

$250,001 - $500,000

Over $1,000,000

Rant and Royalties

Dividends

Excepted Investment Fund

Capital Gaine

Excepted Trust

Qualified Trust

Interest

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X

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Income: type and amount. If "None (or less than $201)" is checked, no other entry is needed in Block C for that item.

Type

Nooe (or less than $1,001)

$1,001-$15,000

$15,001-$50,000

$50,001 - $100,000

$100,001 - $250,000 $500,001 - $1,000,000 $250,001-$500,000

Over $1,000,000

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Tab 4 (Page 9 of 14)

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Income: type and amount. If "None (or less than $201)" is checked, no other entry is needed in Block C for that item.

Туре

Nose (or less than 31,001)

$15,001-$50,000

$1,001-$15.000

$50.00

. $100,000

$100,001-$250,000

$250,001-$500.000

$500,001 - $1,000,000

Over $1,000,000

Rent and Royalties

Dividends

Excepted Investment Pund

Capital Gains

Excepted Trust

Qualified Trust

Interest

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