Form 1099-Int - Interest Income - 2016 Page 8
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9VOID
CORRECTED
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 C
$
PAYER’S federal identification number RECIPIENT’S identification number
3 Interest on U.S. Savings Bonds and Treas. obligations
For Payer
$
RECIPIENT’S name
4 Federal income tax withheld
5 Investment expenses
$
$
For Privacy Act
6 Foreign tax paid
7 Foreign country or U.S. possession
and Paperwork
$
Street address (including apt. no.)
Reduction Act
8 Tax-exempt interest
9 Specified private activity bond
Notice, see the
interest
2016 General
$
$
City or town, state or province, country, and ZIP or foreign postal code
Instructions for
10 Market discount
11 Bond premium
Certain
Information
$
$
Returns.
FATCA filing
requirement
12 Bond premium on Treasury obligations
13 Bond premium on tax-exempt bond
$
$
Account number (see instructions)
2nd TIN not.
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
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