Department of Administrative Services
Enterprise Goods & Services
155 Cottage Street NE
Salem, OR 97301-3969
PHONE: (503) 373-0714
FAX: (503) 378-8940
1099-MISC Change Request
To:
Karlene Hancock, SFMS
Agency Number & Name:______________________________________________________
Requested By:
___________________________________________________________
Authorized Signature*: _______________________________________________________
Phone:
__________________
Fax: _______________________
Reason for Change:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Vendor Name _______________________________________________________
Tax Year: _____
Vendor Number: __________________ Alt ID: _______________
(YYYY)
Change From
Change To
Current Amount Reported
Correct Amount to Report
Box Reported In
On Agency DAFR7940
on 1099-MISC
1 - Rents
___________________
_____________________
3 - Other Income
___________________
_____________________
4 - Backup Withholding
___________________
_____________________
6 - Medical/Health Care
___________________
_____________________
7 - Non Employee Compensation
___________________
___________________
(Subject to Self Employment Tax)
14 – Gross Proceeds paid to an Attorney__________________
_____________________
***************************************************************************
(SFMS use only)
Reference Number_______________
Processed Date_________________