9 2 9 2 VOID CORRECTED

PAYER’S name, street address, city, state, and ZIP code Payer’s RTN (optional) OMB No. 1545-0112

Interest Income

PAYER’S Federal identification number RECIPIENT’S identification number 1 Interest income not included in Box 3 Copy A

$ For

Internal Revenue

Service Center Early withdrawal penalty Interest on U.S. Savings

Bonds and Treas. obligations

RECIPIENT’S name 2 3

File with Form 1096. $ $ For Paperwork

Reduction Act

Notice and

instructions for

completing this

form, see

Instructions for

Forms 1099, 1098,

5498, and W-2G.

Street address (including apt. no.) 4 Federal income tax withheld

$

Foreign country or U.S.

possession

City, state, and ZIP code 5 Foreign tax paid 6

Account number (optional) 2nd TIN Not.

$

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

Do NOT Cut or Separate Forms on This Page

Cat. No. 14410K
CORRECTED (if checked)

PAYER’S name, street address, city, state, and ZIP code Payer’s RTN (optional) OMB No. 1545-0112

Interest Income

PAYER’S Federal identification number RECIPIENT’S identification number 1 Interest income not included in Box 3 Copy B

$ For Recipient

Early withdrawal penalty Interest on U.S. Savings

Bonds and Treas. obligations

RECIPIENT’S name 2 3

$ $

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 this

income is taxable and

the IRS determines that

it has not been

reported.

Street address (including apt. no.) 4 Federal income tax withheld

$

Foreign country or U.S.

possession

City, state, and ZIP code 5 Foreign tax paid 6

Account number (optional)

$

Form 1099-INT (keep for your records) Department of the Treasury - Internal Revenue Service
See Form W-9, Request for Taxpayer Identification Number

and Certification, for information on backup withholding.

Include this amount on your income tax return as tax

withheld.

Instructions for Recipient

Box 1.—Shows interest paid to you during the calendar year

by the payer. This does not include interest shown in Box 3.

Box 5.—Shows foreign tax paid. You may choose to claim

this tax as a deduction or a credit on your Federal income

tax return. See Pub. 514, Foreign Tax Credit for Individuals.

If you receive a Form 1099-INT for interest paid on a

tax-exempt obligation, please see the instructions for your

income tax return.

Box 2.—Shows interest or principal forfeited because of early

withdrawal of time savings. You may deduct this on your

Federal income tax return only on the specific line of Form

1040 under “Adjustments to Income.”

Nominees.—If your Federal identification number is shown

on this form and the form includes amounts belonging to

another person, you are considered a nominee recipient. You

must file Form 1099-INT for each of the other owners

showing the amounts allocable to each. You must also

furnish a Form 1099-INT to each of the other owners. File

Form(s) 1099-INT with Form 1096, Annual Summary and

Transmittal of U.S. Information Returns, with the Internal

Revenue Service Center for your area. On each Form

1099-INT, list yourself as the “payer” and the other owner as

the “recipient.” On Form 1096, list yourself as the “filer.” A

husband or wife is not required to file a nominee return to

show amounts owned by the other.

Box 3.—Shows interest on U.S. Savings Bonds, Treasury

bills, Treasury bonds, and Treasury notes. This may or may

not be all taxable. See Pub. 550, Investment Income and

Expenses. This interest is exempt from state and local

income taxes. This interest is not included in Box 1.

Box 4.—Shows backup withholding. For example, persons

not furnishing their taxpayer identification number to the

payer become subject to backup withholding at a 20% rate.
VOID CORRECTED

PAYER’S name, street address, city, state, and ZIP code Payer’s RTN (optional) OMB No. 1545-0112

Interest Income

PAYER’S Federal identification number RECIPIENT’S identification number 1 Interest income not included in Box 3 Copy C

$ For Payer

Early withdrawal penalty Interest on U.S. Savings

Bonds and Treas. obligations

RECIPIENT’S name 2 3

$ $

For Paperwork

Reduction Act

Notice and

instructions for

completing this

form, see

Instructions for

Forms 1099,

1098, 5498, and

W-2G.

Street address (including apt. no.) 4 Federal income tax withheld

$

Foreign country or U.S.

possession

City, state, and ZIP code 5 Foreign tax paid 6

Account number (optional) 2nd TIN Not.

$

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