Form 1099-Int - Interest Income - 2016 Page 4
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8
9CORRECTED (if checked)
PAYER’S name, street address, city or town, state or province, country, ZIP
Payer's RTN (optional)
OMB No. 1545-0112
or foreign postal code, and telephone no.
Interest
2016
Income
1 Interest income
1099-INT
$
Form
2 Early withdrawal penalty
Copy B
$
PAYER’S federal identification number RECIPIENT’S identification number
For Recipient
3 Interest on U.S. Savings Bonds and Treas. obligations
$
This is important tax
RECIPIENT’S name
4 Federal income tax withheld
5 Investment expenses
information and is
$
$
being furnished to the
Internal Revenue
6 Foreign tax paid
7 Foreign country or U.S. possession
Service. If you are
$
Street address (including apt. no.)
required to file a
8 Tax-exempt interest
9 Specified private activity bond
return, a negligence
interest
penalty or other
sanction may be
$
$
City or town, state or province, country, and ZIP or foreign postal code
imposed on you if
10 Market discount
11 Bond premium
this income is
taxable and the IRS
determines that it has
$
$
FATCA filing
not been reported.
requirement
12 Bond premium on Treasury obligations
13 Bond premium on tax-exempt bond
$
$
Account number (see instructions)
14 Tax-exempt and tax credit
15 State 16 State identification no. 17 State tax withheld
bond CUSIP no.
$
$
1099-INT
(keep for your records)
Form
Department of the Treasury - Internal Revenue Service
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