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+--------+-------------------------+-------------------------+--------+--------+
|00000000| 00 80 d3 4f 43 49 41 4c | 20 d3 45 43 55 52 49 54 |...OCIAL| .ECURIT|
|00000010| 59 20 d4 41 58 20 d7 4f | 52 4b 53 48 45 45 54 20 |Y .AX .O|RKSHEET |
|00000020| 28 31 2d 36 29 0d 2d 2d | 2d 2d 2d 2d 2d 2d 2d 2d |(1-6).--|--------|
|00000030| 2d 2d 2d 2d 2d 2d 2d 2d | 2d 2d 2d 2d 2d 2d 2d 2d |--------|--------|
|00000040| 2d 2d 2d 2d 2d 2d 2d 2d | 2d 0d 31 2e 20 c5 4e 54 |--------|-.1. .NT|
|00000050| 45 52 20 59 4f 55 52 20 | 54 4f 54 41 4c 20 d3 4f |ER YOUR |TOTAL .O|
|00000060| 43 49 41 4c 20 d3 45 43 | 55 52 49 54 59 0d 4f 52 |CIAL .EC|URITY.OR|
|00000070| 20 d2 41 49 4c 52 4f 41 | 44 20 42 45 4e 45 46 49 | .AILROA|D BENEFI|
|00000080| 54 53 2e 0d 0d 32 2e 20 | 35 30 25 20 4f 46 20 4c |TS...2. |50% OF L|
|00000090| 49 4e 45 20 31 2e 0d 0d | 33 2e 20 c5 4e 54 45 52 |INE 1...|3. .NTER|
|000000a0| 20 54 48 45 20 54 4f 54 | 41 4c 20 41 4d 4f 55 4e | THE TOT|AL AMOUN|
|000000b0| 54 53 20 4f 46 20 c6 4f | 52 4d 0d 31 30 34 30 2c |TS OF .O|RM.1040,|
|000000c0| 20 4c 49 4e 45 53 20 37 | 2c 20 38 41 2c 20 39 2d | LINES 7|, 8A, 9-|
|000000d0| 32 30 20 41 4e 44 20 32 | 32 2e 0d 0d 34 2e 20 c5 |20 AND 2|2...4. .|
|000000e0| 4e 54 45 52 20 59 4f 55 | 52 20 54 4f 54 41 4c 20 |NTER YOU|R TOTAL |
|000000f0| 54 41 58 2d 45 58 45 4d | 50 54 0d 49 4e 54 45 52 |TAX-EXEM|PT.INTER|
|00000100| 45 53 54 20 52 45 43 45 | 49 56 45 44 20 28 31 30 |EST RECE|IVED (10|
|00000110| 34 30 2c 20 4c 49 4e 45 | 20 38 42 29 2e 0d 0d 35 |40, LINE| 8B)...5|
|00000120| 2e 20 c5 4e 54 45 52 20 | 54 48 45 20 41 4d 4f 55 |. .NTER |THE AMOU|
|00000130| 4e 54 20 4f 46 20 45 58 | 43 4c 55 44 45 44 0d 49 |NT OF EX|CLUDED.I|
|00000140| 4e 43 4f 4d 45 20 46 52 | 4f 4d 20 d0 55 45 52 54 |NCOME FR|OM .UERT|
|00000150| 4f 20 d2 49 43 4f 20 4f | 52 20 41 53 20 53 48 4f |O .ICO O|R AS SHO|
|00000160| 57 4e 0d 4f 4e 20 4c 49 | 4e 45 20 39 2c 20 c6 4f |WN.ON LI|NE 9, .O|
|00000170| 52 4d 20 34 35 36 33 2e | 0d 0d 36 2e 20 cc 49 4e |RM 4563.|..6. .IN|
|00000180| 45 20 32 20 2b 20 4c 49 | 4e 45 20 33 20 2b 20 4c |E 2 + LI|NE 3 + L|
|00000190| 49 4e 45 20 34 20 2b 20 | 4c 49 4e 45 20 35 2e 0d |INE 4 + |LINE 5..|
+--------+-------------------------+-------------------------+--------+--------+