<?xml version="1.0" encoding="utf-8"?>
<irdInformationReturn xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
	<informationReturnSummary>
		<informationReturnReporter>
			<tin>20072571</tin>
			<branch>1</branch>
			<sender>
				<name>Name</name>
				<email>sample@domain.com</email>
				<phone>1234567</phone>
				<position>position</position>
			</sender>
			<name>Name</name>
			<address>
				<address1>Address1</address1>
				<address2>Address2</address2>
			</address>
		</informationReturnReporter>
		<informationReturnStats>
			<period>201112</period>
			<action>new</action>
			<totalReportees>number</totalReportees>
			<amountReported>amount</amountReported>
		</informationReturnStats>
	</informationReturnSummary>
	<data xsi:type="withHoldingInfoContainer">
		<withHoldingInfo>
			<Reportee>
				<tin>0000000000</tin>
				<branch>0</branch>
				<name>Name</name>
				<address>
					<address1>Address1</address1>
					<address2>Address2</address2>
				</address>
			</Reportee>
			<Interest_Resident_Gross_Income>1.23</Interest_Resident_Gross_Income>
			<Interest_Resident_Amount>1.23</Interest_Resident_Amount>
			<Interest_Non_Resident_Gross_Income>1.23</Interest_Non_Resident_Gross_Income>
			<Interest_Non_Resident_Amount>1.23</Interest_Non_Resident_Amount>
			<Ordinary_Dividends_Gross_Income>1.23</Ordinary_Dividends_Gross_Income>
			<Ordinary_Dividends_Amount>1.23</Ordinary_Dividends_Amount>
			<Preference_Dividends_Gross_Income>1.23</Preference_Dividends_Gross_Income>
			<Preference_Dividends_Amount>1.23</Preference_Dividends_Amount>
			<Royalties_Gross_Income>1.23</Royalties_Gross_Income>
			<Royalties_Amount>1.23</Royalties_Amount>
			<Management_Fees_Gross_Income>1.23</Management_Fees_Gross_Income>
			<Management_Fees_Amount>1.23</Management_Fees_Amount>
			<Entertainment_Fees_Gross_Income>1.23</Entertainment_Fees_Gross_Income>
			<Entertainment_Fees_Amount>1.23</Entertainment_Fees_Amount>
			<Covenanted_Payments_Non_Residents_Gross_Income>1.23</Covenanted_Payments_Non_Residents_Gross_Income>
			<Covenanted_Payments_Non_Residents_Amount>1.23</Covenanted_Payments_Non_Residents_Amount>
			<Rent_Non_Residents_Gross_Income>1.23</Rent_Non_Residents_Gross_Income>
			<Rent_Non_Residents_Amount>1.23</Rent_Non_Residents_Amount>
			<Other_Fees_Non_Residents_Gross_Income>1.23</Other_Fees_Non_Residents_Gross_Income>
			<Other_Fees_Non_Residents_Amount>1.23</Other_Fees_Non_Residents_Amount>
			<Other_Income_Gross_Income>1.23</Other_Income_Gross_Income>
			<Other_Income_Amount>1.23</Other_Income_Amount>
			<After_Tax_Profits_Remitted>1.23</After_Tax_Profits_Remitted>
			<After_Tax_Profits_Withheld>1.23</After_Tax_Profits_Withheld>
			<Registered_Pension_Plan_Amount_Refunded>1.23</Registered_Pension_Plan_Amount_Refunded>
			<Registered_Pension_Plan_Tax_Withheld>1.23</Registered_Pension_Plan_Tax_Withheld>
			<Mutual_Funds_Amount_Redeemed>1.23</Mutual_Funds_Amount_Redeemed>
			<Mutual_Funds_Tax_Withheld>1.23</Mutual_Funds_Tax_Withheld>
			<Mutual_Funds_Purchase_Date>1999-01-21</Mutual_Funds_Purchase_Date>
			<Mutual_Funds_Amount_Purchased>1.23</Mutual_Funds_Amount_Purchased>
			<New_Shares_Public_Company_Amount_Redeemed>1.23</New_Shares_Public_Company_Amount_Redeemed>
			<New_Shares_Public_Company_Tax_Withheld>1.23</New_Shares_Public_Company_Tax_Withheld>
			<New_Shares_Public_Company_Date_Purchased>1999-01-21</New_Shares_Public_Company_Date_Purchased>
			<New_Shares_Public_Company_Amount_Purchased>1.23</New_Shares_Public_Company_Amount_Purchased>
			<Shares_Cooperative_Society_Amount_Redeemed>1.23</Shares_Cooperative_Society_Amount_Redeemed>
			<Shares_Cooperative_Society_Tax_Withheld>1.23</Shares_Cooperative_Society_Tax_Withheld>
			<Shares_Cooperative_Society_Date_Purchased>1999-01-21</Shares_Cooperative_Society_Date_Purchased>
			<Shares_Cooperative_Society_Amount_Purchased>1.23</Shares_Cooperative_Society_Amount_Purchased>
		</withHoldingInfo>
	</data>
</irdInformationReturn>