Chapter Non-Employee Compensation Form


This information is required by the IRS, even if your chapter paid $0.00 to non-employees. The form should be completed after the last day of the calendar year and should be submitted online by January 15th.  Note: If you have more than 3 payments, additional forms may be used.


Chapter Information:

Chapter Name: *
(Please spell out the full chapter name)
Chapter Financial Code: *
(4-digit number that begins with 4_ _ _)
Has your chapter made payments for services in the calendar year ending 12/31?: *
If no, skip the payment section and proceed to the bottom of the form.

1st Payment

Name:
Address:
City:
State:
Zip:
Social Security # or Federal I.D. #:
Service Provided:
Date Service provided:
(mm/dd/yyyy)
Total Amount of Payment:
(Not including travel, hotel or meal expenses)

2nd Payment

Name 2:
Address 2:
City 2:
State 2:
Zip 2:
Social Security # or Federal I.D. # 2:
Service Provided 2:
Date Service provided 2:
(mm/dd/yyyy)
Total Amount of Payment 2:
(Not including travel, hotel or meal expenses)

3rd Payment

Name 3:
Address 3:
City 3:
State 3:
Zip 3:
Social Security # or Federal I.D. # 3:
Service Provided 3:
Date Service provided 3:
(mm/dd/yyyy)
Total Amount of Payment 3:
(Not including travel, hotel or meal expenses)

Further Requests and Comments

Comments:
Your Name: *
Your Email: *
Your Phone Number:
(999-999-9999)

 

 

 

revised 2/13

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