Form 1099-K - Payment Card And Third Party Network Transactions - 2016 Page 3
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8VOID
CORRECTED
FILER'S name, street address, city or town, state or province, country, ZIP
FILER’S federal identification no.
OMB No. 1545-2205
or foreign postal code, and telephone no.
Payment Card and
PAYEE’S taxpayer identification no.
Third Party
2016
Network
1a Gross amount of payment
Transactions
card/third party network
transactions
$
1099-K
Form
1b Card Not Present
2 Merchant category code
Copy 1
transactions
For State Tax
Check to indicate transactions
$
Check to indicate if FILER is a (an):
reported are:
Department
Payment settlement entity (PSE)
3 Number of payment
4 Federal income tax
Payment card
transactions
withheld
Electronic Payment Facilitator
$
(EPF)/Other third party
Third party network
PAYEE’S name
5a January
5b February
$
$
5c March
5d April
$
$
Street address (including apt. no.)
5e May
5f June
$
$
5g July
5h August
$
$
City or town, state or province, country, and ZIP or foreign postal code
5i September
5j October
$
$
PSE'S name and telephone number
5k November
5l December
$
$
Account number (see instructions)
6 State
7 State identification no.
8 State income tax withheld
$
$
1099-K
Form
Department of the Treasury - Internal Revenue Service
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