Form 1099-Int - Interest Income - 2012 (Page 2 of 6) in pdf

Form 1099-Int - Interest Income - 2012 Page 2

VOID

CORRECTED

9292

PAYER’S name, street address, city, state, ZIP code, and telephone no.

Payer's RTN (optional)

OMB No. 1545-0112

2012

1 Interest income

Interest Income

2 Early withdrawal penalty

1099-INT

Form

PAYER’S federal identification number RECIPIENT’S identification number

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

Copy A

For Internal Revenue

Service Center

RECIPIENT’S name

4 Federal income tax withheld

Investment expenses

File with Form 1096.

For Privacy Act and

Paperwork Reduction

Street address (including apt. no.)

6 Foreign tax paid

7 Foreign country or U.S. possession

Act Notice, see the

2012 General

Instructions for

8 Tax-exempt interest

City, state, and ZIP code

Specified private activity bond interest

Certain Information

Returns.

Account number (see instructions)

2nd TIN not.

10 Tax-exempt bond CUSIP no. 11 State 12 State identification no. 13 State tax withheld

1099-INT

Form

Cat. No. 14410K

Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page

Form 1099-Int - Interest Income - 2012 Page 2