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

199 1 Interest Income
PAYER’S Federal identification number | RECIPIENT'S identification number | 1 Interest income not included in Box 3 Copy C
$ For Payer
RECIPIENT'S name 2 Early withdrawal penaty [3 Intereeton US. Savings | Fay Paperwork
Reduction Act
$ Notice and
Street address (including apt. no.) ‘4 Federal income tax withheld YJ lwWWgW instructions for
Wy YJ] completing this
$__ LLL forme see
City, state, and ZIP code 5 Foreign tax paid 6 Foreign country ar US Instructions for
Forms 1099,
‘Account number (optional) 2nd TIN Not. 1098, 5498, and
$ W.2G.
Form 1099-INT Department of the Treasury - Internal Revenue Service

Clvoin = [[) CORRECTED

PAYER’S name, street address, city, state, and ZIP code

Payer's RTN (optional)

OMB No. 1545-0112

1991 Interest Income
PAYER'S Federal identification number | RECIPIENT'S identification number 1 Interest income not included in Box 3 Copy c
$ For Payer

RECIPIENT'S name 2 Early withdrawal penal 3 Interest on U.S. Savings
” penalty | Bonds and tress oblgatins | For Paperwork
Reduction Act
$ Notice and
Street address (including apt. no.) ‘4 Federal income tax withheld instructions for
$ completing this
it = form, see
City, state, and ZIP code 5 Foreign tax paid 6 Foreign county or US. Instructions for
Forms 1099,
‘Account number (optional) 2nd TIN Not. 1098, 5498, and
$ W-2G.
Form 1099-INT Department of the Treasury - Internal Revenue Service

(voi

(1 CoRRECTED

PAYER’S name, street address, city, state, and ZIP code Payer’s RTN (optional) (OMB No. 1545-0112
199 1 | interest Income
PAYER’ Federal identification number | RECIPIENT'S identification number | 1 Interest income not included in Box 3 Copy C
$ For Payer

RECIPIENT'S name 2 Early withdrawal penal 3 Interest on U.S. Savi
" penalty | 3 Bonds and Tress obligations | For Paperwork
Reduction Act
$ Notice and
‘Street address (including apt. no.) 4 Federal income tax withheld y lf YY YY instructions for
$ TMM, etna this
City, state, and ZIP code 5 Foreign tax paid 6 Foci country ‘or U.S. Instructions for
Forms 1099,
Account number (optional) ‘2nd TIN Not. 1098, 5498, and
$ W-2G.

Form 1099-INT

Department of the Treasury - Internal Revenue Service


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.

If you receive a Form 1099-INT for interest paid on a tax-exempt
obligation, please see the insiructions 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.”

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. See Form

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.

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.”

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. See Form

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.

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.”

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. 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.

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.

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.

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.

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.

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.

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.

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.

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.


4292 Clvoiw

(J CORRECTED

‘Type or machine print PAYER'S name, street address, city, stave, and ZIP code

Payer's RTN (optional)

OMB No. 1545-0112

1991

Interest Income

$

$

Street address (including apt. no.)

4 Federal income tax withheld

City, state, and ZIP code

5 Foreign tax paid

‘Account number (optional) 2nd TIN Not.

6 Foreign country or U.S.
possession

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

‘Type or machine print RECIPIENT'S name 2 Early withdrawal penalty 3 Interest on U.S. Savings Internal Revenue
Bonds and Treas. obligations | Service Center

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.

Form 1099-INT

Do NOT Cut or Separate Forms on This Page

Department of the Treasury

- Internal Revenue Service

qeqe2 Civoip —_[_] CORRECTED

Type or machine print PAYER’S name, street address, city, state, and ZIP code | Payer's RTN (optional) ‘OMB No. 1545-0112
1991 Interest Income
PAYER’S Federal identification number | RECIPIENT'S identification number 1 Interest income not included in Box 3 Copy A
$ For
‘Type or machine print RECIPIENT'S name 2 Early withdrawal penalty 3 Interest on U.S. Savings Internal Revenue
Bonds and Treas. obligations | Service Center
$ $ File with Form 1096.
Galo F For Paperwork
Street address (including apt. no.) 4 Federal income tax withheld Reduction Act
$ inst Notice and
5 S Fora r try or U. instructions for
City, state, and ZIP code “oreign tax paid Focele county or completing this
form, see
‘Account number (optional) ‘2nd TIN Not. For aatractions for
$ 5498, and W-2G.

Form 1099-INT

Department of the Treasury -

Do NOT Cut or Separate Forms on This Page

4292 Clvoi

(I CORRECTED

‘Type or machine print PAYER’S name, street address, city, state, and ZIP code

Payer's RTN (optional)

‘OMB No. 1545-0112

1991

Internal Revenue Service

Interest Income

City, state, and ZIP code

5 Foreign tax paid

6 Foreign country or U.S.

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

‘Type or machine print RECIPIENT'S name 2 Early withdrawal penalty 3 Interest on U.S. Savings _ | Internal Revenue
Bonds and Treas. obligations | Service Center

$ $ File with Form 1096.

_ ~ For Paperwork

Street address (including apt. no.) “4 Federal income tax withheld Reduction Act
$ Notice and

instructions for

completing this

possession
form, see
‘Account number (optional) ‘2nd TIN Not. Fora etetions Sor
$ 5498, and W-2G.
Form 1099-INT Department of the Treasury - Internal Revenue Service.




(CD) CORRECTED (if checked)

PAYER’S name, street address, city, state, and ZIP code

Payer's RTN (optional)

OMB No. 1545-0112

Interest Income

1991

PAYER’S Federal identification number | RECIPIENT'S identification number

$

11 Interest income not included in Box 3

Copy B
For Recipient

RECIPIENT'S name

Street address (including apt. no.)

City, state, and ZIP code

2 Early withdrawal penalty

$

“4 Federal Income tax withheld]

'5 Foreign tax paid

‘Account number (optional)

This is important tax

5 Interest on US. Savings information and is

Bonds and Treas. obligations

being furnished tothe

Internal Revenue

WY) yf Stouured efiea
[ll _ _
UMMM Ne

sanction may be
imposed on you if this
income is taxable and
the IRS determines
that it has not been

6 Foreign country or U.S.
Possession

reported.

Form 1099-INT

Department of the Treasury - Internal Revenue Service

(I CORRECTED (if checked)

PAYER'S name, street address, city, state, and ZIP code

Payer’s RTN (optional)

OMB No. 1545-0112

1991

Interest Income

PAYER'S Federal identification number | RECIPIENT'S identification number

$

1 Interest income not included in Box 3

Copy B
For Recipient

RECIPIENT'S name

Street address (including apt. no.)

City, state, and ZIP code

2 Early withdrawal penalty

5 Foreign tax paid

‘Account number (optional)

‘4 Federal Income tax withheld) YW

This is important tax
information and is
being furnished tothe
Internal Revenue
Service. If you are

3 Interest on U.S. Savings
Bonds and Treas. obligations

YY YI YI IY), required to file a

YY Yi Yy YY Yfff. cersrn'a negligence
LA L, penalty or other

6 Foreign country or U.S. sanction may be
possession, imposed on you if this

income is taxable and
the IRS determines
that it has not been

$ reported.
Form 1099-INT Department of the Treasury - Internal Revenue Service
(-] CORRECTED (if checked)
PAYER’S name, street address, city, state, and ZIP code Payer's RTN (optional) ‘OMB No. 1545-0112

1991

Interest Income

PAYER’S Federal identification number | RECIPIENT'S identification number

1 Interest income not included in Box 3

Copy B
For Recipient

RECIPIENT'S name

Street address (including apt. no.)

City, state, and ZIP code

2 Early withdrawal penalty

5 Foreign tax paid

‘Account number (optional)

income tax withheld

This is important tax
information and is
being furnished tothe
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.

3 Interest on U.S. Savings
Bonds and Treas. obligations

possession

Form 1099-INT

Department of the Treasury - Internal Revenue Service