Form 1099-C - Cancellation Of Debt - 2016 (Page 2 of 6) in pdf

Form 1099-C - Cancellation Of Debt - 2016 Page 2

VOID

CORRECTED

8585

CREDITOR'S name, street address, city or town, state or province, country,

1 Date of identifiable event

OMB No. 1545-1424

ZIP or foreign postal code, and telephone no.

Cancellation

2016

2 Amount of debt discharged

of Debt

3 Interest if included in box 2

1099-C

Form

Copy A

CREDITOR'S federal identification number DEBTOR'S identification number

4 Debt description

For

Internal Revenue

DEBTOR'S name

Service Center

File with Form 1096.

5 Check here if the debtor was personally liable for

Street address (including apt. no.)

For Privacy Act and

repayment of the debt

▶

Paperwork Reduction

Act Notice, see the

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

2016 General

Instructions for

Account number (see instructions)

6 Identifiable event code

7 Fair market value of property

Certain Information

Returns.

1099-C

Form

Cat. No. 26280W

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-C - Cancellation Of Debt - 2016 Page 2