PPPP-285 Chargeback 1040-V

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What is the account debtor social security number, with dashes (example, "111-11-1111")?

What is the total chargeback in dollars (example "27997.21")?

What is the account debtor first name middle initial (example "JOHN D")?

What is the account debtor last name (example "SMITH")?

What is the account debtor address street (example "123 MAIN STREET BLDG A")?

What is the account debtor address city (example "NEW YORK")?

What is the account debtor address state (example "NY")?

What is the account debtor postal code (example "11111")?