Form FORM-1099-OID Original Issue Discount

Caution: DRAFT FORM
This is an advance proof copy of an IRS tax form.
It is subject to change and OMB approval before it
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Page 1 of 6 Form 1099-OID (Page 2 is Blank)

Action

3

Date

Signature

O.K. to print
T:FP:F

The type and rule above prints on all proofs including departmental
reproduction proofs. MUST be removed before printing.

O.K. to print
Responsible
scan organization

Date

Revised proofs
requested

INK: Red, J-6983
Separation for 2000 Form 1099-OID Page 1
INK: Black
Separation for 2000 Form 1099-OID Page 1

9696

VOID

CORRECTED

PAYER’S name, street address, city, state, ZIP code, and telephone no.

1 Original issue discount
for 2010

OMB No. 1545-0117

f
o
s
a
9
t
0
f
0
a
2
r
/
D /29
5
0
$

2 Other periodic interest

PAYER’S federal identification number

RECIPIENT’S identification number

2010
1099-OID

$

Form

3 Early withdrawal penalty

4 Federal income tax withheld

$

$

5 Description

RECIPIENT’S name

Street address (including apt. no.)

6 Original issue discount on U.S. Treasury obligations

City, state, and ZIP code

7 Investment expenses

$
$

Account number (see instructions)

Form

1099-OID

2nd TIN not.

Cat. No. 14421R

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—

Original Issue
Discount

Copy A
For
Internal Revenue
Service Center
File with Form 1096.
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2010 General
Instructions for
Forms 1099,
1098, 3921, 3922,
5498, and W-2G.

Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page