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 if 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

Cat. No. 26280W

6

$

4

Form 1099-C

Check for bankruptcy 7 Fair market value of property

$

Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page

Copy A

For

Internal Revenue

Service Center

File with Form 1096.

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2004 General

Instructions for

Forms 1099, 1098,

5498, and W-2G.

2004
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 if 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

$

2004
Instructions for Debtor

If a Federal government agency, certain agency connected

with the Federal government, financial institution, credit

union, or an organization having a significant trade or

business of lending money (such as a finance or credit card

company) 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 Form 1040. 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 are not includible in your

income, such as certain student loans (see Pub. 525), certain

debts reduced by the seller after purchase (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). 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 a canceled debt from your

income because it was canceled in a bankruptcy case or

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, box 5 shows a description of the property.

Box 3. Shows interest if 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.

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).
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 if 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

$

4

Form 1099-C

6 7 Check for bankruptcy Fair market value of property

$

For Creditor

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2004 General

Instructions for

Forms 1099,

1098, 5498,

and W-2G.

Copy C

2004
Instructions for Creditors

General and specific form instructions are provided as

separate products. The products you should use to complete

Form 1099-C are the 2004 General Instructions for Forms

1099, 1098, 5498, and W-2G, and the separate specific

instructions, 2004 Instructions for Forms 1099-A and

1099-C. A chart in the general instructions gives a quick

guide to which form must be filed to report a particular

payment. To order these instructions and additional forms,

call 1-800-TAX-FORM (1-800-829-3676).

Due dates. Furnish Copy B of this form to the debtor by

January 31, 2005.

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

2005. If you file electronically, the due date is March 31,

2005.

Caution: Because paper forms are scanned during

processing, you cannot file Forms 1096, 1098, 1099, or 5498

that you download and print from the IRS website.