1099-INT 2011Draft

Caution: DRAFT FORM
This is an advance proof copy of an IRS tax form.
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Page 1 of 6 of Form 1099-INT (Page 2 is Blank)

3

Action

Separation 1: Red

9292

Signature

O.K. to print
Responsible
scan organization

Separation 1 for page 1 of Form 1099-INT. Prints in
Red (J-6983) Ink.
Separation 2 for page 1 of Form 1099-INT. Prints in Black Ink.

Date

Date

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.

Revised proofs
requested

Separation 2: Black

VOID

CORRECTED

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

Payer’s RTN (optional)

OMB No. 1545-0112

2011

1 Interest income

$

Interest Income

2 Early withdrawal penalty

f
o
s
a
0
t
1
f
0
a
2
r
/
D /17
6
0
$

PAYER’S federal identification number

RECIPIENT’S identification number

Form

1099-INT

3 Interest on U.S. Savings Bonds and Treas. obligations

$

RECIPIENT’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (see instructions)

Form

1099-INT

4 Federal income tax withheld

5 Investment expenses

$

$

Copy A
For
Internal Revenue
Service Center
File with Form 1096.

For Privacy Act and
7 Foreign country or U.S. possession Paperwork Reduction
Act Notice, see the
2011 General
$
Instructions for
8 Tax-exempt interest
9 Specified private activity bond interest
Certain Information
Returns.
$
$
2nd TIN not. 10 Tax-exempt bond CUSIP no. (see instructions)
6 Foreign tax paid

Cat. No. 14410K

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Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page