CORRECTED (if checked)
1
Rents
OMB No. 1545-0115
$
Miscellaneous
2
Royalties
2
013
Income
$
Form
 
1099-MISC
City
3
Other income
4
Federal income tax withheld
Copy B
Telephone no.
$
$
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
This is important tax
of dividends or interest
information and is
being furnished to
the Internal Revenue
$
$
Service. If you are
Street address (including apt. no.)
9
Payer made direct sales of
10
Crop insurance proceeeds
required to file a
Apartment no.
$5,000 or more of consumer
return, a negligence
products to a buyer
penalty or other
(recipient) for resale
G
$
sanction may be
City
State     ZIP Code
11
12
imposed on you if
this income is
Account number (see instructions)
13
Excess golden parachute
14
Gross proceeds paid to
taxable and the IRS
payments
an attorney
determines that it
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
$
/
$
$
$
$
/
$
Form 
1099-MISC
(keep for your records)            Department of the Treasury - Internal Revenue Service
Payer’s Name
PAYER’S INFORMATION
Street address (including apt. no.)
Street address (line 2)
State   
  ZIP Code
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