Form 1099-Oid - Original Issue Discount - 2016 Page 4
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9CORRECTED (if checked)
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 B
PAYER’S federal identification number RECIPIENT’S identification number
$
$
5 Market discount
6 Acquisition premium
For Recipient
RECIPIENT’S name
$
$
7 Description
This is important tax
information and is
Street address (including apt. no.)
being furnished to
the Internal Revenue
Service. If you are
required to file a
City or town, state or province, country, and ZIP or foreign postal code
8 Original issue discount on
* This may not be the correct
return, a negligence
figure to report on your income
U.S. Treasury obligations*
penalty or other
tax return. See instructions on
sanction may be
the back.
$
imposed on you if
this income is
9 Investment expenses
10 Bond premium
FATCA filing
taxable and the IRS
requirement
determines that it
has not been
$
$
reported.
Account number (see instructions)
11 State 12 State identification no. 13 State tax withheld
$
$
1099-OID
(keep for your records)
Form
Department of the Treasury - Internal Revenue Service
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