Form 1099-Oid - Original Issue Discount - 2012 Page 3
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6CORRECTED (if checked)
PAYER’S name, street address, city, state, ZIP code, and telephone no.
1 Original issue discount for
OMB No. 1545-0117
2012*
2012
Original Issue
$
Discount
2 Other periodic interest
1099-OID
$
Form
Copy B
PAYER’S federal identification number RECIPIENT’S identification number
3 Early withdrawal penalty
4 Federal income tax withheld
For Recipient
$
$
This is important tax
RECIPIENT’S name
5 Description
information and is
being furnished to the
Internal Revenue
Service. If you are
Street address (including apt. no.)
6 Original issue discount on U.S. Treasury obligations*
required to file a return,
a negligence penalty or
$
other sanction may be
* This may not be the correct figure to
7 Investment expenses
City, state, and ZIP code
imposed on you if this
report on your income tax return. See
income is taxable and
$
instructions on the back.
the IRS determines that
Account number (see instructions)
8 State 9 State identification no.
10 State tax withheld
it has not been
reported.
$
1099-OID
(keep for your records)
Form
Department of the Treasury - Internal Revenue Service
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