Form 1099-C - Cancellation Of Debt - 2016 (Page 3 of 6) in pdf

Form 1099-C - Cancellation Of Debt - 2016 Page 3

CORRECTED (if checked)

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 B

CREDITOR'S federal identification number DEBTOR'S identification number

4 Debt description

For Debtor

This is important tax

DEBTOR'S name

information and is being

furnished to the Internal

Revenue Service. If you

are required to file a

5 If checked, the debtor was personally liable for

Street address (including apt. no.)

return, a negligence

repayment of the debt

penalty or other

▶

sanction may be

imposed on you if

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

taxable income results

from this transaction

and the IRS determines

Account number (see instructions)

6 Identifiable event code

7 Fair market value of property

that it has not been

reported.

1099-C

(keep for your records)

Form

Department of the Treasury - Internal Revenue Service

Form 1099-C - Cancellation Of Debt - 2016 Page 3