33 - NOTICE of 1099A - Gov - Uscourts.ord.124749.33.0, NOTICE OF 1099A
33 - NOTICE of 1099A - Gov - Uscourts.ord.124749.33.0, NOTICE OF 1099A
33 - NOTICE of 1099A - Gov - Uscourts.ord.124749.33.0, NOTICE OF 1099A
Legal Document
Oregon District Court
Case No. 3:15-cr-00438
USA v. Shrout
Document 33
View Document
View Docket
Case 3:15-cr-00438-JO
Document 33
Filed 04/15/16
Page 1 of 2
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97123-9998
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By: Winston Shrout. as Real Party in Interest, 3rd Party Interest Intervenor under Injury, Sole
Shareholder in WINSTON SHROUT, Settlor/Beneficiary of WINSTON SHROUT 401643573
NOTICE OF FILING OF IRS FORM 1099A ON Case No. 3:15-cr-00438-JO
----------------------------CORRECTED (if checked)
OMB No. 1545-0877
LENDER'S name, street address, city or town, state or province, country, ZIP or
foreign postal code, and telephone no.
WINSTON SrlROUT
c/I) PO BOX l./OJ.13
HIJ..CSf30R.~ OR
~16
Form
v 712.3
Acquisition or
Abandonment of
Secured Property
1099-A
2 Balance of principal
outstanding
~73
U-V\ L Y1 /)U)
$ U.Nf<ll'OWN
4D
~~2~V2=~"~-=~-1.__.:.....:..:"-:...i..:...!....:-=::::........L----t;-:-:".i~~r:;;i~~~~~~;k.rt;;;~-;;f;:;;;;;;;rtv1
1
1-L/
BORROWER'S name
CopyB
For Borrower
Thisisimportanttax
information and is being
3
4 Fair market value of property furnished to the Internal
1,4 !ti/(.
Revenue Service. If you
are required to file a
$
return, a negligence
penalty or other
5 If checked, the borrower was personally liable for repayment
sanction may be
of the debt . . .
. . . . . . . ~
imposed on you if
taxable income results
from this transaction
and the IRS determines
that it has not been
reported.
/V 0 WA/
1000
Form
SW 1'1JR0
1099-A
By:tJ~.~
Winston Shrout
www.irs.gov/form1099a
'Ill~ /tip
date
Case 3:15-cr-00438-JO
Document 33
Filed 04/15/16
Page 2 of 2
PROOF OF SERVICE
Be it known that on the date of March---' 2016, that a copy of this above was served at the
place of business to the following:
Billy J. Williams, US Attorney, Bar# unknown
c/o US District Court, Mark 0. Hatfield US Courthouse
1000 SW Third Avenue, ste 600
Portland, Oregon 97204