Form 1097-BTC Bond Tax Credit

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Page 1 of 6 of Form 1097-BTC (Page 2 is BLANK)

7

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

Separation 1 for page 1 of Form 1097-BTC. Prints in
Red (J-6983) Ink.
Separation 2 for page 1 of Form 1097-BTC. Prints in Black Ink.

VOID

Signature

O.K. to print
Responsible
scan organization

Date

5050

Date

O.K. to print
T:FP:F

Revised proofs
requested

CORRECTED

FORM 1097-BTC ISSUER’S name, street address, city, state, ZIP code,
and telephone no.

1a Bond issue date

OMB No. XXXX-XXXX

2010

1b Maturity date

Form

1097-BTC

Bond
Tax
Credit

1c CUSIP no.

FORM 1097-BTC ISSUER’S federal
identification number

RECIPIENT’S identification number

2 Code (see instructions)

3

Stated principal

Copy A
$
RECIPIENT’S name

Street address (including apt. no.)

City, state, and ZIP code

4a March 15, 2010,
allowance date credit

4b June 15, 2010,
allowance date credit

$

$

4c September 15, 2010,
allowance date credit

4d December 15, 2010,
allowance date credit

$

$

5 Check one:
Issuer of bond or its agent filing initial 2010
Form 1097-BTC for this bond

BOND ISSUER’S name

An entity that received a 2010 Form 1097-BTC for
this bond

For
Internal Revenue
Service Center
File with Form 1096.
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2010 General
Instructions for
Certain Information
Returns.

BOND ISSUER’S employer identification number

Form

1097-BTC

Cat. No. 54293T

Do Not Cut or Separate Forms on This Page

—

Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page

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Page 3 of 6 of Form 1097-BTC

7

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

CORRECTED (if checked)
FORM 1097-BTC ISSUER’S name, street address, city, state, ZIP code,
and telephone no.

1a Bond issue date

OMB No. XXXX-XXXX

2010

1b Maturity date

Form

1097-BTC

Bond
Tax
Credit

1c CUSIP no.

FORM 1097-BTC ISSUER’S federal
identification number

RECIPIENT’S identification number

2

Code (see instructions)

3 Stated principal

$
RECIPIENT’S name

4a March 15, 2010,
allowance date

4b June 15, 2010,
allowance date

$

$

Street address (including apt. no.)

4c September 15, 2010,
allowance date

4d December 15, 2010,
allowance date

$

$

City, state, and ZIP code

5 Check one:
Issuer of bond or its agent filing initial 2010
Form 1097-BTC for this bond

BOND ISSUER’S name

An entity that received a 2010 Form 1097-BTC for
this bond

Copy B
For Recipient
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 an
amount of tax credit
exceeding the amount
reported on this form is
claimed on your
income tax return.

BOND ISSUER’S employer identification number

Form

1097-BTC

(keep for your records)

Department of the Treasury - Internal Revenue Service

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Page 4 of 6 of Form 1097-BTC

7

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

Instructions for Recipient
Issuers of certain tax credit bonds (or their agents) and
nominees/intermediaries (such as a broker, a
partnership, a trust, an estate, a regulated investment
company, or a real estate investment trust) must report
to you quarterly and file with the IRS annually a
separate Form 1097-BTC for each tax credit
distributed to you.
Bond issuer’s name. Shows the name of the entity
issuing the tax credit bond from which the credit is
being distributed.

Box 2. The codes for tax credit bonds issued are:
101 – Qualified forestry conservation bond,
102 – New clean renewable energy bond,
103 – Qualified energy conservation bond,
104 – Qualified zone academy bond,
105 – Qualified school construction bond,
107 – Midwestern tax credit bond,
108 – Other, and

Bond issuer’s identification number. Shows the
identification number of the entity issuing the tax credit
bond from which the credit is being distributed.

109 – Build America bond.
Box 3. Shows the stated principal of the bond.

Box 1a. Shows the issue date of the bond.
Box 1b. Shows the bond maturity date.

Box 4a–4d. Shows the amount of the credit distributed
to you with respect to this allowance date.

Box 1c. Shows the CUSIP (Committee on Uniform
Securities Identification Procedures) number of each
bond. If “None” is written in the box, the bond issue
either has no CUSIP number or is privately placed.

Box 5. Shows if the filer or its agent is the original filer
of this form, or is an entity that received this form. This
information will help the IRS track distribution of tax
credits from this bond.

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Page 5 of 6 of Form 1097-BTC

7

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

VOID

CORRECTED

FORM 1097-BTC ISSUER’S name, street address, city, state, ZIP code,
and telephone no.

1a Bond issue date

OMB No. XXXX-XXXX

2010

1b Maturity date

Form

1097-BTC

1c CUSIP no.

FORM 1097-BTC ISSUER’S federal
identification number

RECIPIENT’S identification number

2

Code (see instructions)

3

Bond
Tax
Credit

Stated principal

$
RECIPIENT’S name

Street address (including apt. no.)

City, state, and ZIP code

4a March 15, 2010,
allowance date credit

4b June 15, 2010,
allowance date credit

$

$

4c September 15, 2010,
allowance date credit

4d December 15, 2010,
allowance date credit

$

$

5 Check one:
Issuer of bond or its agent filing initial 2010
Form 1097-BTC for this bond

BOND ISSUER’S name

Copy C
For Payer
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2010 General
Instructions for
Certain Information
Returns.

An entity that received a 2010 Form 1097-BTC for
this bond

BOND ISSUER’S employer identification number

Form

1097-BTC

Department of the Treasury - Internal Revenue Service

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Page 6 of 6 of Form 1097-BTC

7

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

Instructions for Payer
General and specific form instructions are provided as
separate products. The products you should use for
2010 are the General Instructions for Certain
Information Returns and the 2010 Instructions for Form
1097-BTC. A chart in the general instructions gives a
quick guide to which form must be filed to report a
particular payment. To order these instructions and
additional forms, visit the IRS website at www.IRS.gov
or call 1-800-TAX-FORM (1-800-829-3676).
Caution: Because paper forms are scanned during
processing, you cannot file with the IRS Forms 1096,
1097, 1098, 1099, 3921, 3922, or 5498 that you print
from the IRS website.
Due dates. Furnish Copy B of this form to the
recipient quarterly and separately for each credit
amount indicated and for each bond on or before the
15th day of the second calendar month after the close
of the calendar quarter in which the credit is issued.
File Copy A of this form with the IRS by
February 28, 2011. If you file electronically, the due
date is March 31, 2011. To file electronically, you must

have software that generates a file according to the
specifications in Pub. 1220, Specifications for Filing
Forms 1098, 1099, 3921, 3922, 5498, 8935, and W-2G
Electronically. IRS does not provide a fill-in form
option.
Foreign recipient. If the recipient of the tax credits
from this tax credit bond is a nonresident alien, you
may have to withhold federal income tax and file Form
1042-S, Foreign Person’s U.S. Source Income Subject
to Withholding. See the Instructions for Form 1042-S
and Pub. 515, Withholding of Tax on Nonresident
Aliens and Foreign Entities.
Need help? If you have questions about reporting on
Form 1097-BTC, call the information reporting
customer service site toll free at 1-866-455-7438 or
304-263-8700 (not toll free). For TTY/TDD equipment,
call 304-579-4827 (not toll free). The hours of operation
are Monday through Friday from 8:30 a.m. to
4:30 p.m., Eastern time.

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Printed on recycled paper