Form 4804 Transmittal of Information Returns Reported Magnetically

(See Instructions on back)

Department of the Treasury – Internal Revenue Service

Form 4804

Transmittal of Information Returns
Reported Magnetically

(Rev. May 2002)

Please type or print in BLACK ink

IRS Use Only

OMB No.
1545-0367

(Use a separate Form 4804 for each file.)
2. Tax year for
which media is
submitted

1. Type of file represented by this transmittal

¨

Original

¨ Test

¨

Replacement

¨ Correction

3. Transmitter Control Code (TCC) (Required)

4. Name of transmitter (Owner of TCC)

5. Name/address of company and name/title of person who should receive correspondence on problem files
(should be the same information as in 'T' record)

Company Name
Address ____________________________________________________________________
City ____________________________________ State ____________ Zip _______________
Contact Person ______________________ Telephone Number (_____) ________________
E-mail Address ______________________________________________________________
6. Forms 1098, 1099, 5498,
W-2G Combined total of payee
'B' records

7. Form 1042-S
Total number of 'Q'
records

8. Form 8027 Total number of
establishment(s) reported

9. Transmitter in-house
media number(s)

Affidavit
Under penalties of perjury, I declare that I have examined this transmittal, including accompanying
documents, and, to the best of my knowledge and belief, it is correct and complete.
(Normally, the payer must sign the affidavit above. The authorized agent of the payer may sign if all
conditions are met as stated on the back.)

SIGNATURE (Required)

Title

IRS Use Only

Date

Catalog Number 27210I

Form 4804 (Rev. 5-2002)

Form 4804 (Rev. 5-2002)
General Instructions
Paperwork Reduction Act Notice. We ask for the information on
these forms to carry out the Internal Revenue Laws of the United
States. You are not required to provide the information requested
on a form that is subject to the Paperwork Reduction Act unless
the form displays a valid OMB control number. Books or records
relating to a form must be retained as long as their contents may
become material in the administration of any Internal Revenue
law. Generally, tax returns and return information are confidential,
as required by Code section 6103.
The time needed to provide this information would vary
depending on individual circumstances. The estimated average
time is:
Preparing Form 4804 . . . . . . . . . . . . . . . . . . . . . . . 15 min.

Block 3
Enter the five-character alpha/numeric Transmitter Control Code
assigned by IRS. TCCs for Form 1042-S filing begin with the
numbers 22. TCCs for Form 8027 filing begin with the numbers 21.
Block 4
Enter the name of
Requirements below.)

the transmitter.

(Reference Affidavit

Block 5
Enter the name and address of the company, along with the
name/title of the person to whom correspondence concerning
problem media in need of replacement should be sent. This
information should match the information that appears in the
Transmitter 'T' Record in your file. Please include an email address
if available

If you have comments concerning the accuracy of these time
estimates or suggestions for making this form simpler, we would
be happy to hear from you. You can write to the Tax Forms
Committee, Western Area Distribution Center, Rancho Cordova,
CA 95743-0001.
DO NOT SEND THE FORMS TO THIS OFFICE. Instead, see the
instructions below on where to file. When completing this form,
please type or print clearly in BLACK ink.

NOTE: IRS no longer returns media in need of replacement.

Purpose of Form. Use Form 4804 when submitting the following
types of information returns magnetically: Form 1098, 1099,
5498, W-2G, 1042-S, and 8027. You must include Form 4804 with
all magnetic media you submit to the Internal Revenue Service.

Block 6
Enter the combined number of all payee 'B' records on the media
sent with this Form 4804.

NOTE: A separate Form 4804 must be submitted for each file.
Specific Instructions
Block 1

Indicate whether the data in this shipment is an original,
correction, replacement or test file by checking the
appropriate box. Check ‘Replacement’ only if you are
sending media in response to a specific request from
IRS/MCC and you have a Form 9267 attached.

Block 6,7,8
Use only the boxes appropriate to the forms you are reporting. A
separate Form 4804 is required for the information returns in box 6,
1042-S Forms in box 7, and 8027 Forms in box 8.

Block 7
If reporting Form 1042-S, enter the total number Recipient ‘Q’
records.
Block 8
If reporting Form 8027, enter the number of establishments
reported.
Block 9
If your organization uses an in-house numbering system to identify
media, indicate the media number(s) in the appropriate block.

Definitions
Correction: A correction is an information return submitted by
the payer to correct erroneous information previously sent to and
processed by IRS/MCC.
Replacement: A replacement is an information return file sent by
the filer at the request of IRS/MCC because of errors
encountered while processing the filer's original return. Your
replacement file may be submitted electronically even if the
original file was sent on magnetic media.
Block 2
Indicate the tax year for which media is being submitted.

Mailing Address:
Send your media with transmittal Form(s) 4804 to the address
below:
IRS, Martinsburg Computing Center
Information Reporting Program
230 Murall Drive
Kearneysville, WV 25430
NOTE: Form 4802, Transmittal of Information Returns Reported
Magnetically/Electronically (Continuation) is obsolete.

Affidavit Requirement
A transmitter, service bureau, paying agent, or disbursing agent (all hereafter referred to as “agent”) may sign Form
4804 on behalf of the payer (or other person required to file), if the conditions in items 1 and 2 are met:
1. The agent has the authority to sign the form under an agency agreement (oral, written, or implied) that is valid
under state law.
2. The agent signs the form and adds the caption “For: (Name of payer or other person required to file)”.
he authorized agent’s signing of the affidavit on the payer’s behalf does not relieve the payer of the responsibility
for filing a correct, complete, and timely Form 4804, with attachments, and will not relieve the payer of any penalties
for not complying with those requirements.