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Holder Reporting
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Enter Holder Information:
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Primary Holder Info section header
Primary Holder Info
*
Holder Name
:
*
Holder Tax ID
:
*
Holder ID
:
?
?
*
Contact Name
:
*
Contact Phone Number
:
*
Phone Extension
:
*
Email Address
:
*
Email Address Confirmation
:
*
State
:
- Select an Option -
AA-APO
AE-APO
Alabama
Alaska
American Samoa
AP-APO
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
U.S. Minor Outlying Islands
Utah
Vermont
Virginia
U.S. Virgin Islands
Washington
West Virginia
Wisconsin
Wyoming
Report Info section header
Report Info
*
Report Type
:
Holder Report
Auditor Report
Reciprocal State Report
*
Report Year
:
- Select an Option -
2019
2020
2021
2022
2023
2024
*
Total Dollar Amount Remitted
:
*
Funds Remitted Via
:
- Select an Option -
ACH
Wire
Check
Online
*
Does this report include records that are subject to the HIPAA Privacy Rule?
:
?
Yes
No
?
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