Form 1096 - Annual Summary And Transmittal Of U.s. Information Returns - 2012 Page 2
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36969
Do Not Staple
1096
OMB No. 1545-0108
Annual Summary and Transmittal of
Form
12
20
U.S. Information Returns
Department of the Treasury
Internal Revenue Service
FILER'S name
Street address (including room or suite number)
City, state, and ZIP code
For Official Use Only
Name of person to contact
Telephone number
Email address
Fax number
1 Employer identification number 2 Social security number
3 Total number of forms
4 Federal income tax withheld
5 Total amount reported with this Form 1096
$
$
6 Enter an “X” in only one box below to indicate the type of form being filed.
7 If this is your final return, enter an “X” here
.
.
.
.
.
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W-2G
1097-BTC
1098
1098-C
1098-E
1098-T
1099-A
1099-B
1099-C
1099-CAP
1099-DIV
1099-G
1099-H
1099-INT
32
50
81
78
84
83
80
79
85
73
91
86
71
92
1099-K
1099-LTC
1099-MISC
1099-OID
1099-PATR
1099-Q
1099-R
1099-S
1099-SA
3921
3922
5498
5498-ESA
5498-SA
10
93
95
96
97
31
98
75
94
25
26
28
72
27
Return this entire page to the Internal Revenue Service. Photocopies are not acceptable.
Under penalties of perjury, I declare that I have examined this return and accompanying documents, and, to the best of my knowledge and belief, they are true, correct,
and complete.
Signature
Title
Date
▶
▶
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Instructions
When to file. File Form 1096 as follows.
• With Forms 1097, 1098, 1099, 3921, 3922, or W-2G, file by February
Reminder. The only acceptable method of filing information returns
28, 2013.
with Internal Revenue Service/Information Returns Branch is
• With Form 5498, file by May 31, 2013.
electronically through the FIRE system. See Pub. 1220, Specifications
for Filing Forms 1097, 1098, 1099, 3921, 3922, 5498, 8935, and W-2G
Where To File
Electronically.
Send all information returns filed on paper with Form 1096 to the
Purpose of form. Use this form to transmit paper Forms 1097, 1098,
following:
1099, 3921, 3922, 5498, and W-2G to the Internal Revenue Service.
Do not use Form 1096 to transmit electronically. For electronic
If your principal business, office
Use the following
submissions, see Pub. 1220.
or agency, or legal residence in
three-line address
the case of an individual, is
Caution. If you are required to file 250 or more information returns of
located in
any one type, you must file electronically. If you are required to file
electronically but fail to do so, and you do not have an approved
waiver, you may be subject to a penalty. For more information, see
Alabama, Arizona, Arkansas,
part F in the 2012 General Instructions for Certain Information Returns.
Connecticut, Delaware, Florida, Georgia,
Kentucky, Louisiana, Maine,
Department of the Treasury
Who must file. The name, address, and TIN of the filer on this form
Massachusetts, Mississippi, New
Internal Revenue Service Center
must be the same as those you enter in the upper left area of Forms
Hampshire, New Jersey, New Mexico,
Austin, TX 73301
1097, 1098, 1099, 3921, 3922, 5498, or W-2G. A filer is any person or
New York, North Carolina, Ohio,
entity who files any of the forms shown in line 6 above.
Pennsylvania, Rhode Island, Texas,
Vermont, Virginia, West Virginia
Enter the filer’s name, address (including room, suite, or other unit
number), and TIN in the spaces provided on the form.
1096
Cat. No. 14400O
Form
(2012)
For more information and the Privacy Act and Paperwork Reduction Act Notice,
see the 2012 General Instructions for Certain Information Returns.
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