Form 1099-Oid - Original Issue Discount - 2016 Page 3
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9VOID
CORRECTED
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 1
PAYER’S federal identification number RECIPIENT’S identification number
$
$
For State Tax
5 Market discount
6 Acquisition premium
Department
RECIPIENT’S name
$
$
7 Description
Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
8 Original issue discount on
U.S. Treasury obligations
$
FATCA filing
9 Investment expenses
10 Bond premium
requirement
$
$
Account number (see instructions)
11 State 12 State identification no. 13 State tax withheld
$
$
1099-OID
Form
Department of the Treasury - Internal Revenue Service
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