Form 1099-C - Cancellation Of Debt - 2016 Page 5
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6VOID
CORRECTED
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 C
CREDITOR'S federal identification number DEBTOR'S identification number
4 Debt description
For Creditor
DEBTOR'S name
For Privacy Act
and Paperwork
Reduction Act
5 Check here if the debtor was personally liable for
Street address (including apt. no.)
Notice, see the
repayment of the debt
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▶
2016 General
City or town, state or province, country, and ZIP or foreign postal code
Instructions for
Certain Information
Returns.
Account number (see instructions)
6 Identifiable event code
7 Fair market value of property
$
1099-C
Form
Department of the Treasury - Internal Revenue Service
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Parent category: Financial