Form 1099-Int - Interest Income - 2016 (Page 6 of 9) in pdf

Form 1099-Int - Interest Income - 2016 Page 6

CORRECTED (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 2

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

To be filed with

6 Foreign tax paid

7 Foreign country or U.S. possession

recipient's state

Street address (including apt. no.)

income tax

8 Tax-exempt interest

9 Specified private activity bond

return, when

interest

required.

City or town, state or province, country, and ZIP or foreign postal code

10 Market discount

11 Bond premium

FATCA filing

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

Form

Department of the Treasury - Internal Revenue Service

Form 1099-Int - Interest Income - 2016 Page 6