Reporting Year

Company Name

Location Address

Delivery Address

City

State Code

Zip Code

Foreign Address

Foreign State/Province

Foreign Postal Code

Country Code

Submitter Name

Submitter Location Address

Submitter Delivery Address

Submitter City

Submitter State Code

Submitter Zip Code

Submitter Foreign Address

Submitter Foreign State/Province

Submitter Foreign Postal Code

Submitter Country Code

Submitter EIN

Method of Notification

Preparer Code

Contact Person

Phone Number

Fax Number

EMail

MMREF PIN