9292 VOID CORRECTED

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

Interest Income

PAYER’S Federal identification number RECIPIENT’S identification number 1 Interest income not included in box 3

$

Early withdrawal penalty Interest on U.S. Savings

Bonds and Treas. obligations

RECIPIENT’S name 2 3

$ $

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

$

Foreign country or U.S.

possession

City, state, and ZIP code 6 Foreign tax paid 7

Account number (optional) 2nd TIN not.

$

Form 1099-INT Cat. No. 14410K Department of the Treasury - Internal Revenue Service

Form 1099-INT

5 Investment expenses

$

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)

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

Interest Income

PAYER’S Federal identification number RECIPIENT’S identification number 1 Interest income not included in box 3

$

Early withdrawal penalty Interest on U.S. Savings

Bonds and Treas. obligations

RECIPIENT’S name 2 3

$ $

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

$

Foreign country or U.S.

possession

City, state, and ZIP code 6 Foreign tax paid 7

Account number (optional)

$

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

Copy B

For Recipient

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.

(keep for your records)

Form 1099-INT

5 Investment expenses

$

2004
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 6. Shows foreign tax paid. You may be able to claim this

tax as a deduction or a credit on your Form 1040. See your

Form 1040 instructions.

If you receive a Form 1099-INT for interest paid on a taxexempt obligation, 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 amount to

figure your adjusted gross income on your income tax return.

See the instructions for Form 1040 to see where to take the

deduction.

Nominees. If this form includes amounts belonging to

another person(s), you are considered a nominee recipient.

Complete a Form 1099-INT for each of the other owners

showing the income allocable to each. File Copy A of the

form with the IRS. Furnish Copy B to each owner. List

yourself as the “payer” and the other owner(s) as the

“recipient.” 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 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. Generally, a payer must

backup withhold at a 28% rate if you did not furnish your

taxpayer identification number (TIN) or you did not furnish

the correct TIN to the payer. 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. Any amount shown is your share of investment

expenses of a single-class REMIC. If you file Form 1040, you

may deduct these expenses on the “Other expenses” line of

Schedule A (Form 1040) subject to the 2% limit. This

amount is included in box 1.
VOID CORRECTED

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

Interest Income

PAYER’S Federal identification number RECIPIENT’S identification number 1 Interest income not included in box 3

$

Early withdrawal penalty Interest on U.S. Savings

Bonds and Treas. obligations

RECIPIENT’S name 2 3

$ $

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

$

Foreign country or U.S.

possession

City, state, and ZIP code 6 Foreign tax paid 7

Account number (optional) 2nd TIN not.

$

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

Form 1099-INT

5 Investment expenses

$

For Payer

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 Payers

General and specific form instructions are provided as

separate products. The products you should use to complete

Form 1099-INT are the 2004 General Instructions for

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

specific instructions, 2004 Instructions for Forms 1099-INT

and 1099-OID. 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 recipient 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.

Forms 1099-INT and 1098. If you received mortgage interest

in the course of your trade or business, you may have to

report it to the payer of such mortgage interest and to the

IRS on Form 1098, Mortgage Interest Statement. Do not

report mortgage interest to the payer on Form 1099-INT. The

purpose of Form 1098 is to report a mortgage interest

deduction. The purpose of Form 1099-INT is to report

interest income. See the Instructions for Forms 1099-INT

and 1099-OID, and the Instructions for Form 1098.

Foreign recipient. If the recipient is a nonresident alien, you

may have to withhold Federal income tax and file Form

1042-S, Foreign Person’s U.S. Source Income Subject to

Withholding. See the Instructions for Form 1042-S and

Pub. 515, Withholding of Tax on Nonresident Aliens and

Foreign Entities.

Caution: Because paper forms are scanned during

processing, you cannot file with the IRS Forms 1096, 1098,

1099, or 5498 that you download and print from the IRS

website.