Form 1099-Oid - Original Issue Discount - 2012 Page 5
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6VOID
CORRECTED
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
PAYER’S federal identification number RECIPIENT’S identification number
3 Early withdrawal penalty
4 Federal income tax withheld
Copy C
$
$
For Payer
RECIPIENT’S name
5 Description
For Privacy Act
and Paperwork
Street address (including apt. no.)
6 Original issue discount on U.S. Treasury obligations
Reduction Act
$
Notice, see the
2012 General
7 Investment expenses
City, state, and ZIP code
Instructions for
$
Certain Information
Returns.
Account number (see instructions)
2nd TIN not.
8 State 9 State identification no.
10 State tax withheld
$
1099-OID
Form
Department of the Treasury - Internal Revenue Service
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