CORRECTED (if checked)

1RentsOMB No. 1545-0115

$

Miscellaneous

2Royalties

2013Income

$

Form 1099-MISC

City

3Other income4Federal income tax withheldCopy B

Telephone no.

$$For Recipient

PAYER’S federal identification numberRECIPIENT’S identification number

5Fishing boat proceeds6Medical and health care payments

RECIPIENT’S name7Nonemployee compensation8Substitute payments in lieuThis is important tax

of dividends or interestinformation and is

being furnished to

the Internal Revenue

$$Service. If you are

Street address (including apt. no.)9Payer made direct sales of10Crop insurance proceeedsrequired to file a

Apartment no.$5,000 or more of consumerreturn, a negligenceproducts to a buyerpenalty or other

(recipient) for resaleG$sanction may be

CityState     ZIP Code1112imposed on you if

this income is

Account number (see instructions)13Excess golden parachute14Gross proceeds paid totaxable and the IRS

paymentsan attorneydetermines that it

has not been

$$reported.

15aSection 409A deferrals15bSection 409A income16State tax withheld17State/ Payer’s state no.18State 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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