VOID CORRECTED

CREDITOR’S name, street address, city, state, and ZIP code OMB No. 1545-1424

Cancellation

of Debt

CREDITOR’S Federal identification number DEBTOR’S identification number 1 Date canceled 2 Amount of debt canceled

$

3 Interest included in box 2

5

DEBTOR’S name

Street address (including apt. no.) Debt description

City, state, and ZIP code

Account number (optional)

Form 1099-C Department of the Treasury - Internal Revenue Service

8585

Copy A

For Paperwork

Reduction Act

Notice and

instructions for

completing this form,

see Instructions for

Forms 1099, 1098,

5498, and W-2G.

File with Form 1096.

Do NOT Cut or Separate Forms on This Page

Cat. No. 26280W

For

Internal Revenue

Service Center

6

$

4

Form 1099-C

Check for bankruptcy 7 Fair market value of property

$

96

$

Penalties, fines, admin.

costs included in box 2
CORRECTED (if checked)

CREDITOR’S name, street address, city, state, and ZIP code OMB No. 1545-1424

Cancellation

of Debt

CREDITOR’S Federal identification number DEBTOR’S identification number 1 Date canceled 2 Amount of debt canceled

$

3 Interest included in box 2

5

DEBTOR’S name

Street address (including apt. no.) Debt description

City, state, and ZIP code

Account number (optional)

Form 1099-C Department of the Treasury - Internal Revenue Service

Copy B

For Debtor

This is important tax

information and is being

furnished to the Internal

Revenue Service. If you

are required to file a

return, a negligence

penalty or other

sanction may be

imposed on you if

taxable income results

from this transaction

and the IRS determines

that it has not been

reported.

(Keep for your records.)

4

$

Form 1099-C

6 7 Bankruptcy (if checked) Fair market value of property

$

96

$

Penalties, fines, admin.

costs included in box 2
Instructions for Debtor

If a Federal Government agency, financial institution, or credit

union cancels or forgives a debt you owe of $600 or more,

this form must be provided to you. Generally, if you are an

individual, you must include the canceled amount on the

“Other income” line of your tax return. If you are a

corporation, partnership, or other entity, report the canceled

debt on your tax return. See the instructions for your tax

return.

However, some canceled debts, such as certain student

loans (see Pub. 525), certain purchase money debt (see Pub.

334), qualified farm debt (see Pub. 225), qualified real

property business debt (see Pub. 334), or debts canceled in

bankruptcy (see Pub. 908), are not includible in your income.

Do not report a canceled debt as income if you did not

deduct it but would have been able to do so on your tax

return if you had paid it. Also, do not include canceled debts

in your income to the extent you were insolvent. If you

exclude canceled debt from your income because it was

canceled in a bankruptcy case or during insolvency, or

because the debt is qualified farm debt or qualified real

property business debt, file Form 982, Reduction of Tax

Attributes Due to Discharge of Indebtedness (and Section

1082 Basis Adjustment).

Box 1.—Shows the date the debt was canceled.

Box 2.—Shows the amount of debt canceled.

Box 6.—If the box is marked, the creditor has indicated the

debt was canceled in a bankruptcy proceeding.

Box 5.—Shows a description of the debt. If box 7 is

completed, also shows a description of the property.

Box 3.—Shows the amount of interest included in the

canceled debt in box 2. See Pub. 525, Taxable and

Nontaxable Income.

Box 7.—If, in the same calendar year, a foreclosure or

abandonment of property occurred in connection with the

cancellation of the debt, the fair market value of the property

will be shown, or you will receive a separate Form 1099-A,

Acquisition or Abandonment of Secured Property. You may

have income or loss because of the acquisition or

abandonment. See Pub. 544, Sales and Other Dispositions

of Assets, for information about foreclosures and

abandonments.

Box 4.—Shows penalties, fines, or adminstrative costs

included in box 2 as part of the canceled debt.
VOID CORRECTED

CREDITOR’S name, street address, city, state, and ZIP code OMB No. 1545-1424

Cancellation

of Debt

CREDITOR’S Federal identification number DEBTOR’S identification number 1 Date canceled 2 Amount of debt canceled

$

3 Interest included in box 2

5

DEBTOR’S name

Street address (including apt. no.) Debt description

City, state, and ZIP code

Account number (optional)

Form 1099-C Department of the Treasury - Internal Revenue Service

Copy C

For Creditor

For Paperwork

Reduction Act

Notice and

instructions for

completing this

form, see

Instructions for

Forms 1099,

1098, 5498,

and W-2G.

$

4

Form 1099-C

6 7 Check for bankruptcy Fair market value of property

$

96

$

Penalties, fines, admin.

costs included in box 2
Creditors, Please Note—

Specific information needed to complete this form and other

forms in the 1099 series is given in the 1996 Instructions for

Forms 1099, 1098, 5498, and W-2G. A chart in those

instructions gives a quick guide to which form must be filed

to report a particular payment. You can order those

instructions and additional forms by calling 1-800-TAX-FORM

(1-800-829-3676).

Furnish Copy B of this form to the debtor by January 31,

1997.

File Copy A of this form with the IRS by February 28,

1997.

Printed on recycled paper