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

$

RECIPIENT’S name 4 Federal income tax withheld 5 Investment expenses

$ $

Street address (including apt. no.) 6 Foreign tax paid

$

City, state, and ZIP code 8 Tax-exempt interest 9 Specified private activity bond interest

Account number (see instructions) 2nd TIN not.

$

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

Form 1099-INT

7 Foreign country or U.S. possession

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

2011 General

Instructions for

Certain Information

Returns.

2 Early withdrawal penalty

$

1 Interest income

$ 2011

10 Tax-exempt bond CUSIP no. (see instructions)

$
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

RECIPIENT’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (see instructions)

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

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

$

4 Federal income tax withheld 5 Investment expenses

$ $

6 Foreign tax paid

$

7

2 Early withdrawal penalty

$

1 Interest income

$ 2011

8 Tax-exempt interest 9 Specified private activity bond interest

$

10 Tax-exempt bond CUSIP no. (see instructions)

$

Foreign country or U.S. possession
Instructions for Recipient

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

payer. This does not include interest shown in box 3. May also show the total

amount of the credits from clean renewable energy bonds, Gulf tax credit

bonds, qualified forestry conservation bonds, new clean renewable energy

bonds, qualified energy conservation bonds, qualified zone academy bonds,

Midwestern tax credit bonds, qualified school construction bonds, and build

America bonds that must be included in your interest income. These amounts

were treated as paid to you during 2011 on the credit allowance dates (March

15, June 15, September 15, and December 15). For more information, see

Form 8912, Credit to Holders of Tax Credit Bonds.

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.

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 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 all be taxable. See Pub. 550. 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 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. Include this amount on

your income tax return as tax withheld.

Box 5. Any amount shown is your share of investment expenses of a singleclass 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.

Account number. May show an account or other unique number the payer

assigned to distinguish your account.

Box 8. Shows tax-exempt interest, including exempt-interest dividends from a

mutual fund or other regulated investment company, paid to you during the

calendar year by the payer. Report this amount on line 8b of Form 1040 or

Form 1040A. This amount may be subject to backup withholding. See box 4.

Box 9. Shows tax-exempt interest subject to the alternative minimum tax. This

amount is included in box 8. See the Instructions for Form 6251.

Box 10. Shows CUSIP number(s) for tax-exempt bond(s) on which tax-exempt

interest was paid to you during the calendar year and reported in box 8. If

blank, no CUSIP number was issued for the bond(s).
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

RECIPIENT’S name

City, state, and ZIP code

Account number (see instructions) 2nd TIN not.

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

Form 1099-INT

For Payer

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2011 General

Instructions for

Certain Information

Returns.

Copy C

Street address (including apt. no.)

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

$

4 Federal income tax withheld 5 Investment expenses

$ $

6

$

8 9

7

2 Early withdrawal penalty

$

1 Interest income

$

$

2011

Specified private activity bond interest

Foreign country or U.S. possession

10 Tax-exempt bond CUSIP no. (see instructions)

Foreign tax paid

Tax-exempt interest

$
Instructions for Payer

General and specific form instructions are provided as

separate products. The products you should use to complete

Form 1099-INT are the 2011 General Instructions for Certain

Information Returns and the 2011 Instructions for Forms

1099-INT and 1099-OID. To order these instructions and

additional forms, visit IRS.gov or call 1-800-TAX-FORM

(1-800-829-3676).

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

January 31, 2012.

File Copy A of this form with the IRS by February 28, 2012.

If you file electronically, the due date is April 2, 2012. To file

electronically, you must have software that generates a file

according to the specifications in Pub. 1220, Specifications

for Filing Forms 1097, 1098, 1099, 3921, 3922, 5498, 8935,

and W-2G Electronically. IRS does not provide a fill-in form

option.

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. See

the instructions for Form 1098 for information on reporting

mortgage interest.

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, 1097,

1098, 1099, 3921, 3922, or 5498 that you print from the IRS

website.

Need help? If you have questions about reporting on Form

1099-INT, call the information reporting customer service site

toll free at 1-866-455-7438 or 304-263-8700 (not toll free).

For TTY/TDD equipment, call 304-579-4827 (not toll free).

The hours of operation are Monday through Friday from

8:30 a.m. to 4:30 p.m., Eastern time.