Form 1099-K Merchant Card for Third Party Payments

Attention:
This form is provided for informational purposes only. Copy A appears in red, similar
to the official IRS form. Do not file copy A downloaded from this website. The official
printed version of this IRS form is scannable, but the online version of it, printed from
this website, is not. A penalty of $50 per information return may be imposed for filing
forms that cannot be scanned.

To order official IRS forms, call 1-800-TAX-FORM (1-800-829-3676) or Order
Information Returns and Employer Returns Online, and we’ll mail you the
scannable forms and other products.
See IRS Publications 1141, 1167, 1179 and other IRS resources for information
about printing these tax forms.

1010

VOID

CORRECTED

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

FILER’S federal identification no. OMB No. 1545-2205

2011

PAYEE’S taxpayer identification no.

Form
1 Gross amount of merchant
card/third party network
payments

1099-K

2

Copy A
For
Internal Revenue
Service Center

$

Check box if FILER is Payment Settlement Entity (PSE)

4

3

Merchant Card
and Third Party
Network Payments

OR
Check box if FILER is Electronic Payment Facilitator (EPF)/
Third Party Payer (TPP)

File with Form 1096.
5a

PAYEE’S name

January

5b

March

5d

$

$
5c
Street address (including apt. no.)

$
5e

5g

May

5f

5i

5h

July

August

$
September

$
5k

June

$

$

PSE’S name and telephone number

April

$

$
City, state, and ZIP code

February

5j

October

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2011 General
Instructions for
Certain Information
Returns.

$
November

$

5l

December

$

Account number (see instructions)

Form

1099-K

Department of the Treasury - Internal Revenue Service

Cat. No. 54118B

Do Not Cut or Separate Forms on This Page

—

Do Not Cut or Separate Forms on This Page

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

FILER’S federal identification no. OMB No. 1545-2205

2011

PAYEE’S taxpayer identification no.

Form
1 Gross amount of merchant
card/third party network
payments
If checked, FILER is Payment Settlement Entity (PSE)

Merchant Card
and Third Party
Network Payments

1099-K

2

Copy B
For Payee

$
4

3

OR
If checked, FILER is Electronic Payment Facilitator (EPF)/
Third Party Payer (TPP)
PAYEE’S name

5a

January

5c
Street address (including apt. no.)

March

$
5e

5g

May

5i

July

$

April

5f

June

5h

August

$
September

$
5k

5d

$

$

PSE’S name and telephone number

February

$

$
City, state, and ZIP code

5b

$

$

5j

October

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
taxable income
results from this
transaction and the
IRS determines that it
has not been
reported.

$
November

5l

December

$

Account number (see instructions)

Form

1099-K

(Keep for your records)

Department of the Treasury - Internal Revenue Service

Instructions for Payee
Merchant card and third party network payers, as
payment settlement entities (PSE), must report the
proceeds of payment card and third party network
transactions made to you on Form 1099-K under
Internal Revenue Code section 6050W. You have
received this form because you have accepted
merchant cards for payments, or because you received
payments through a third party network that exceeded
$20,000 in gross total reportable payment transactions
and the total number of those transactions exceeded
200 for the calendar year.
The PSE may have contracted with an electronic
payment facilitator (EPF) or other third party payer
(TPP) to make payments to you. If you have questions
about the amounts reported on this form, contact the
FILER whose information is shown in the upper left
corner on the front of this form. If you do not recognize
the FILER shown in the upper left corner of the form,

contact the PSE whose name and phone number are
shown in the lower left corner of the form above your
account number.
Account number. May show an account or other
unique number the PSE assigned to distinguish your
account.
Box 1. Shows the aggregate gross amount of
merchant card/third party network payments made to
you through the PSE during the tax year.
Boxes 5a–5l. Shows the gross amount of merchant
card/third party network payments received by you for
each month of the reporting calendar year. This
amount is provided to assist you in the accurate
preparation of your fiscal year tax return.

VOID

CORRECTED

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

FILER’S federal identification no. OMB No. 1545-2205

2011

PAYEE’S taxpayer identification no.

Form
1 Gross amount of merchant
card/third party network
payments
Check box if FILER is Payment Settlement Entity (PSE)

Merchant Card
and Third Party
Network Payments

1099-K

2

Copy C
For Filer

$
4

3

OR
Check box if FILER is Electronic Payment Facilitator (EPF)/
Third Party Payer (TPP)
PAYEE’S name

5a

January

5b

March

5d

$

$
5c
Street address (including apt. no.)

$
5e

5g

May

July

$

June

5h

August

$
September

$
5k

5f

$

$
5i

PSE’S name and telephone number

April

$

$
City, state, and ZIP code

February

5j

October

$
November

5l

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2011 General
Instructions for
Certain Information
Returns.

December

$

Account number (see instructions)

Form

1099-K

Department of the Treasury - Internal Revenue Service

Instructions for Payment Settlement
Entity/Third Party Payer
General and specific form instructions are provided as
separate products. The products you should use to
complete Form 1099-K are the 2011 General
Instructions for Certain Information Returns and the
2011 Instructions for Form 1099-K. 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 IRS.gov or
call 1-800-TAX-FORM (1-800-829-3676).
Caution: Because paper forms are scanned during
processing, you cannot file 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 by January 31, 2012.

File Copy A of this form with the IRS by February 28,
2012. If you file electronically, the due date is
April 2, 2012. To file electronically, you must have
software that generates a file according to the
specifications in Pub. 1220, Specifications for Filing
Forms 1097, 1098, 1099, 3921, 3922, 5498, 8935, and
W-2G Electronically. IRS does not provide a fill-in form
option.
Need help? If you have questions about reporting on
Form 1099-K, 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.

Printed on recycled paper