EFTA01222597.pdf

CORRECTED (if checked) PAYER'S name. street address, city or town. state or province. country. ZIP Payees RTN (optional) OMB No. 1545-0112 or foreign postal code, and telephone no. Interest 1 Interest income 2017 Income $ Form 1099-INT 2 Early withdrawal penalty Copy B PAYER'S federal identification number RECIPIENT'S identification number $ For Recipient 3 Interest on U.S. Savings Bands and Treas. obligations $ This is important tax RECIPIENT'S name 4 Federal income tax withheld 5 Investment expenses information and is $ $ being fumished to the 6 Foreign tax paid 7 Foreign country or U.S. possesson Internal Revenue Service. If you are Street address (including apt. no.) $ required to file a 8 Tax-exempt interest 9 Speerlied paves, activry bond return. a negligence interest penalty or other sanction may be City or town. state or prcntnce. county, and ZIP or foreign postal code $ $ imposed on you if 10 Market discount 11 Bond premeurn this income is taxable and the IRS determines that it has FATCA filing $ $ not been reported. requirement 12 Bcnd prentrn en Treats/ ctignors 13 Bond premium on tax-exempt bond O $ $ Account number (see instructions) 14 Tax-exempt and tax credit 15 Slate 18 State itentificaton no. 17 State tax withheld bond CUSIP no. $ $ Form 1099-INT (keep for your records) www.irs.goy/form1099int Department of the Treasury - Internal Revenue Service EFTA01222597