fs oosaas BRS Per ae eRR | Notice CUA Tax Year 2012 Notice date ‘pn 20: 2045 IRS Socal Security number 031-56-5975 Page 3 of 6 Ghanges to your 2012 tax retum Your income and dedictions Toucan ___ twee Sees eat sags acum ds buon 0 so $2 Inset i $0 Fs 5 Income net dtference $937 Change to arabe income $337 Your tax computations onan um rereandby SOs Terabe incomes Ene 23 sia) 534 7 Tai ie 44 57.136 S73 $38 ‘Toxin quai pl king RAs and St tattooed actus, 68 0 $185. $186 Total ta fe 6 37786 57560. $424 Taxyou ove siz Explanation of changes to your 2012 Form This secon tls you speclicaly what ncome iformaton te IR reved about you 1040 Health Savings Account from athers (including your employers, banks, mortgage holders, etc). This information doesn't match the information you reported on your tax return. Use the table to compare the data the IRS receive from ater to the information you feported on your tax return to undersand vere the diference(s) occured. To assist you in reviewing your income amounts, the table may include both reported and unreported amounts. Distribution Receive rom sates coun eaten, Stooron ‘eum _Reponed wBSbyathes __Dierence JPNORGAN CHASE BANK WA P 0 80x 30207 (68397079884439 $0 $932 $932 HSA SUB CUSTODIAN AETWA TAMPA FL 336303207 s514031-56-5975 Fem 1099-58 interest sce fan aires cunt oation Shown. etn _ Reported RS by thers __ Orne JPMORGAN CHASE BANK NA, PO BOX 659749 102995000000402893279 30 3 3 SAM ANTONIO TX 78265. $SN031-56-5975 Form 1099:1NT IPMORGAN CHASE BAN NA Po nox esa740 ‘2995000000870812852 0 2 8 SAN ANTOMIO TX 78765. SSN 031-56-5975 Form 1099.1NT Interest Total 7) 6 5 20% Tax on Health Savings Account distributions Premature distributions from a Health Savings Account are subject to an addtional 20% tax. A distribution is considered premature i twas paid before you reached age 65. The 20% taxis based on the taxable portion of the distribution. Exceptions may apply as incicated in Publication 969, Health Savings Accounts and Other Tax-Favored Health Pans. If the distbution(s) shown on this notice are exempt from the additonal ‘x, please send usa signed explanation. Continued an back.BRST I Notice RDI9A Tax Year 2012 Notice date ‘Api 20,3015 Social Security number 031-56:5975 Page 4 of 6 Health savings account distribution The Health Savings Account distribution reportd on your return daes not agree with the information provided tous on Formis) 1099-58, Distbutions From an HSA, Archer MSA, or Medicare Advantage MSA. Form W-2 or 1099 not received The aw requis you to report your income correctly your payers did no send you a yeatly income statement (Farm W-2, Form 1099, etc), you must use the information you have (pay stubs, monthly income statements, deposit lips, et.) to estimate the Total amount of income you received during the year. lisidentified income {f any of the income shawn on this notice isnot yous, send us the name, address, and social security number ofthe person who received the income. Please notify the payers to correct their records to show the name and social security number of the person who actually received te income, so that fulure reports to us are accurate, Interest charges ‘We are required by law to charge interest on unpaid tax Tom the date the tax retuin ‘was due tothe date the taxis paid in ful. The interest is charged as long as there is an Lunpaidl amount due, including penalties, if applicable. (Internal Revenue Code section 6601)oosses FORM 5564(cv. une 1992) Deparment fe Teasuy-— neta Ravens Serie Symbols NOTICE OF DEFICIENCY - WAIVER ear ‘athe and Ares Tapes) DEREK M SNOW Apri 20, 2015 2300 STH AVE APT 8° NEW YORK Ny 10037-1615, 031-56-5975 Kind of Tax ‘© Copy to Authorized Representative Individual income "Tax Year Ended DEFICIENCY Increase in Tx $424 Penalties December 31, 2012 IMME “03156597520121" ' consent tothe immediate assessment and colection of the deficiencies {increase in tax and penattis) shown above, plus any interest. Also, | waive the ‘requirement under section 6532 (a) (1) ofthe internal Revenue Cade that a notice of claim dislowsance be sant ta me by ceria! mall or any cwerpaymant shown onthe attached report | undeistand thatthe fling of this waiver i revocable and it wl begin the 2-year tid for fling sult for efud ofthe claims disallowed as if the notice of isslowance had been sent by cert ar egistered mal Date Date Signature By Tile Date Note: if you consent to the assessment of the defiancies shown inthis waives, please sign and return this form to limit the iatawest charge and ‘expedite cur bil 10 you, Please donot sign are return any pce notices you may have received. Yout consent signature i required on this waive, ever if fully aid, Your consent will nat prevent you from fling a claim for refund (after you have pid theta) if you later beteve you are sO ented; nor prevent us Om later determining if necessary, that you owe atonal tax nar extend the time provided ty law for such action. HY you later file 9 cai and the Senice csaliows you may fe suit fr refund in 3 Disc Court or in the United Stats Clim Court, but you may net fle @perivon with the Unite States Tax Cour. Who Must Sign: iyo Med joint, bath you sr yout spouse must sgn. Your attomey or agent may sgn his waiver provided that action is peticay zuthorzed by a power of auacrey which, fact prenousty fied, must aeampary som, HE this waiver is signed by a person acting in a fduiny capacty (or xample, an executor, administrator o 2 wus! Fo 56, Nate Concemning Fiduca Reatonsi, shoul, ness revousy fe, accompany ths torn If you agree, please sign and return this form; keep one copy for your records, FORM 5564 (801.692)Use this address if you are enclosing a payment: Internal Revenue Service feldbere 1. Choose appropriate address 2. Fold page so correct address appears in window. feldbere Use this address if you are NOT enclosing’ payment! Internal Revenue Service PO BOX 621505,