Form 1099-B - Proceeds From Broker And Barter Exchange Transactions - 2016 Page 3
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9VOID
CORRECTED
PAYER'S name, street address, city or town, state or province, country, ZIP
Applicable check box on Form 8949
OMB No. 1545-0715
Proceeds From
or foreign postal code, and telephone no.
2016
Broker and
Barter Exchange
Transactions
1099-B
Form
1a Description of property (Example 100 sh. XYZ Co.)
1b Date acquired
1c Date sold or disposed
Copy 1
PAYER'S federal identification number
RECIPIENT'S identification number
1d Proceeds
1e Cost or other basis
$
$
For State Tax
Department
1f Accrued market discount
1g Wash sale loss disallowed
$
$
RECIPIENT'S name
2 Short-term gain or loss
3 If checked, basis reported
to IRS
Long-term gain or loss
Ordinary
Street address (including apt. no.)
4 Federal income tax withheld
5 If checked, noncovered
security
$
6 Reported to IRS:
7 If checked, loss is not allowed
based on amount in 1d
City or town, state or province, country, and ZIP or foreign postal code
Gross proceeds
Net proceeds
8 Profit or (loss) realized in
9 Unrealized profit or (loss) on
2016 on closed contracts
open contracts—12/31/2015
Account number (see instructions)
$
$
CUSIP number
FATCA filing
10 Unrealized profit or (loss) on
11 Aggregate profit or (loss)
requirement
open contracts—12/31/2016
on contracts
$
$
14 State name
15 State identification no. 16 State tax withheld
$
12 Check if proceeds from
13 Bartering
collectibles
$
$
1099-B
Form
Department of the Treasury - Internal Revenue Service
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