Form 1099-Misc - Miscellaneous Income - 2017

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CORRECTED (if checked)
PAYER’S name, street address, city or town, state or province, country, ZIP
1 Rents
OMB No. 1545-0115
or foreign postal code, and telephone no.
Miscellaneous
2017
$
Income
2 Royalties
$
1099-MISC
Form
Copy B
3 Other income
4 Federal income tax withheld
$
$
For Recipient
PAYER’S federal identification number RECIPIENT’S identification number
5 Fishing boat proceeds
6 Medical and health care payments
$
$
RECIPIENT’S name
7 Nonemployee compensation
8 Substitute payments in lieu of
This is important tax
dividends or interest
information and is
being furnished to
the Internal Revenue
$
$
Street address (including apt. no.)
Service. If you are
required to file a
9 Payer made direct sales of
10 Crop insurance proceeds
return, a negligence
$5,000 or more of consumer
products to a buyer
penalty or other
$
City or town, state or province, country, and ZIP or foreign postal code
(recipient) for resale
sanction may be
imposed on you if
11
12
this income is
taxable and the IRS
13 Excess golden parachute
14 Gross proceeds paid to an
Account number (see instructions)
FATCA filing
determines that it
requirement
payments
attorney
has not been
reported.
$
$
15a Section 409A deferrals
15b Section 409A income
16 State tax withheld
17 State/Payer’s state no.
18 State income
$
$
$
$
$
$
1099-MISC
(keep for your records)
Form
Department of the Treasury - Internal Revenue Service

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