Form 
1099-INT
20
13
Interest Income
Copy B
For Recipient
Department of the Treasury - Internal Revenue Service
This is important tax 
information and is 
being furnished to the 
Internal Revenue 
Service. If you are 
required to file a 
return, a negligence 
penalty or other 
sanction may be 
 imposed on you if 
this income is 
taxable and the IRS 
determines that it has 
not been reported.
OMB No. 1545-0112
CORRECTED (if checked)
PAYER’S federal identification number
RECIPIENT’S identification number
RECIPIENT’S name
Street address (including apt. no.)
City or town, province or state, country, and ZIP or foreign postal code
Account number (see instructions)
Payer's RTN (optional)
1 
Interest income
$
2 
Early withdrawal penalty
$
3 
Interest on U.S. Savings Bonds and Treas. obligations
$
4 
Federal income tax withheld
$
5 
Investment expenses
$
6 
Foreign tax paid
$
7 
Foreign country or U.S. possession
8 
Tax-exempt interest
$
9  
Specified private activity bond 
interest
$
10 
Tax-exempt bond CUSIP no.
11 
State
12 
State identification no.
13 
State tax withheld
$
$
Form 
1099-INT
(keep for your records)
www.irs.gov/form1099int
City
State       ZIP Code
Payer’s Name
Street address (including apt. no.)
Telephone no.
PAYER’S INFORMATION
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