Form 1099-Oid - Original Issue Discount - 2016 Page 2
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8
9VOID
CORRECTED
9696
PAYER’S name, street address, city or town, state or province, country, ZIP
1 Original issue discount for
OMB No. 1545-0117
or foreign postal code, and telephone no.
2016
$
Original Issue
2016
2 Other periodic interest
Discount
1099-OID
$
Form
3 Early withdrawal penalty
4 Federal income tax withheld
Copy A
PAYER’S federal identification number RECIPIENT’S identification number
$
$
For
5 Market discount
6 Acquisition premium
Internal Revenue
Service Center
RECIPIENT’S name
$
$
7 Description
File with Form 1096.
Street address (including apt. no.)
For Privacy Act
and Paperwork
City or town, state or province, country, and ZIP or foreign postal code
8 Original issue discount on
Reduction Act
U.S. Treasury obligations
Notice, see the
$
2016 General
9 Investment expenses
10 Bond premium
FATCA filing
Instructions for
requirement
Certain
Information
$
$
Returns.
Account number (see instructions)
2nd TIN not.
11 State 12 State identification no. 13 State tax withheld
$
$
1099-OID
Form
Cat. No. 14421R
Department of the Treasury - Internal Revenue Service
Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page
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