Form 1099-Int - Interest Income - 2012 (Page 5 of 6) in pdf

Form 1099-Int - Interest Income - 2012 Page 5

VOID

CORRECTED

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

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 and

Paperwork Reduction

Act Notice, see the

2012 General

Street address (including apt. no.)

6 Foreign tax paid

7 Foreign country or U.S. possession

Instructions for

Certain Information

8 Tax-exempt interest

Returns.

City, state, and ZIP code

Specified private activity bond interest

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

Department of the Treasury - Internal Revenue Service

Form 1099-Int - Interest Income - 2012 Page 5