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CORRECTED (if checked) PAYER'S name,street address,city,stale,Z""ode;and telephone no. 1 Rents �. - OMB No.1545-0115 KAISER FOUNDATION HE H PLAN INC. $ 0.00j 2001 Miscellaneous 1950 FRANKLIN STREET, 5TH FLOOR Royelhea OAKLAND, CA 94612 $ 0.00 Form 1099—MISC Income (510) 987-1754 other income 4 Federal income lax withhold $ 0.00 $ 0.00 PAYER'S Federal identification number RECIPIENT'S identification number Fishing boat prowads Medial antl health cera payments 94r $ 0�00 $ 11,00 {�� 9p RECIPIENT'S name,Street address(Including apt.no.),City,state,and ZIPcotle 7 Nonemployee compensation BSubstltule payments in lieu of TO I]eOT11,Qy tlividends or interest colllo COUNTY OF SAN JOAQUIN $ 818.00 $ 0.00 (ecgpient s OFFICE OF EMERGENCY SERVICES Payer made direct sales of$5,000 10 Crop insurance proceeds state IhC me or more of consumer products toe fax re ur[nt buyer (recipient)for resale ► reques etl. 222 EAST WEBER AVE. RM. 610 v ( a' ) ❑ 0.00 STOCKTON, CA 95202 11e: &gasp°`'»9:ay3kisoc�: l7tat :reoa° to'< o?'$'::a: M:: 'n'oon.:$::R.S. . ....o>..... $.. S:.RR �' ..4 . 0.6.'S'.�': Account number(optional) Excess golden parachute payrrems 10r.e.proceeds paid to an attorney $ Is is 15 State income tax withheld 1751ate/Payer's state number 16 Slate income $ CA 91012294 $ Form 1099—MISC Department of the Treasury-Internal Revenue Service ❑ CORRECTED (if checked) PAYER'S name,street address,city,slate,ZIP cad.,and telephone no. 1 Rents OMB No.15450115 KAISER FOUNDATION HEALTH PLAN INC. $ 0.00 2001 Miscellaneous 1950 FRANKLIN STREET, 5TH FLOOR Royalties OAKLAND, CA 94612 $ 0.00 orm 1099—MISC Income (510) 987-1754 Other income 6 Federal income tax withheld $ 0.00 $ 0.00 PAYER'S Federal identification number RECIPIENT'Sl do tilication number Fishing boat proceeds Medical and health care payments _ $ 0.010 $ 0,00 7 Nonem RECIPIENT'S name,Street address(including apt.no.),CRY,state,and ZIP code ployee compensation Bdividends ubstit t.payments in lieu of or interest COUNTY OF SAN JOAQUIN $ 818.00 $ 0.00 OFFICE OF EMERGENCY SERVICES Payer made direct sales of$5,000 10 Crop insurance proceeds or more of consumer products to a $ 0.00 222 EAST WEBER AVE. RM. 610 buyer recipient)far resale ►❑ %gn°a^ a:o: :s3�`::''�o:o.'yo:`o:r. 2 >f' ;'.o O�.By°a"I..'u?s°5��o°g'3R STOCKTON, CA 95202 11> °St a a&8' >'<1 omR..&w�i...n.)bon...R......'.. ..:.,..:'<a,?o�'0..«0..32"R:<R..'.�2: :h<R' Account number(options Excessgolaen parachutepaymen 14 Gross proceeds paid.toanattorney $ $ 16 16 State income lex withheld 17 State/Payer's state number 16 Stale income $ CA 91012294 $ Department of the Treasury-Internal Revenue Service Form CORRECTED (if checked) PAYER'S name,slreel address,city,state,ZIP code,and latephone no. 1 Rents OMB No.1545.0115 KAISER FOUNDATION HEALTH PLAN INC. $ 0.00 001 Miscellaneous 1950 FRANKLIN STREET, 5TH FLOOR Royalties OAKLAND, CA 94612 $ 0.00 Form 1099—MISC Income (510) 987-1754 Other income rFed.r.1 income lax withheld $ 0.00 $ 0.00 PAYER'S Federal identification number RECIPIENT'S Itlenlification number 5 Fishing boat proceeds Viiiardical and healthcare payments Copy B 94-1340523 946000531 $ 0.00 $ 0.00 For Recipient 7 Nonemployee compensation 5Substitute payments in lieu of This is Important tax RECIPIENT'S name,Street address(including apt.no.),City,state,and ZIP code dividends or interest information and is being rnal COUNTY OF SAN JOAQUIN $ 818.00 $ 0.00 Revenue furnished envie.If you Revenue Service.If you OFFICE OF EMERGENCY SERVICES Payer made direct sales of$5,000 10 Crop insurance Proceeds are required to file or more of consumer products toe o return,a negligence 222 EAST WEBER AVE. RM. 610 buyer (reciplanpforresale ►❑ $ 0.00 penalty or other sanctin STOCKTON, CA 95202 11>`°s`°^, $2ae°g owmr�r""°"R+:`s 17"e bff`"'Q`'ra if ttns mmbe me imposed an you .Re oa3C: oa. o eRn�. oR'._._. .. is taxable and the IRS Account number(optional) 14 Excess golden mrachule payment 14Gross proceeds paid to an attorney determines that It hes $ $ not been reported. 15 State Income lax withheld 5tate/Payer's slate number 18 State Income $ CA 91012294 $ Farm 10 — Department of the Treasury-Internal Revenue Service