Form 14420 Verification of Reported Income

Form 14420
(October 2012)

Department of the Treasury - Internal Revenue Service

OMB Number
1545-

Verification of Reported Income

Taxpayer name

Taxpayer Identification Number

For tax year ending

Step 1 - Verify the Form 1099-K information below and note any corrections
Filer's Name

Filer’s Federal
ID Number

Reported Merchant
Category Code
and industry (Box 2)

Reported Gross
Amount from Form
1099-K (Box 1)

Information
correct
(check Yes or No)

$

Yes

No

$

Yes

No

$

Yes

No

$

Yes

No

$

Yes

No

• If any of the income shown above isn't yours, identify the Form(s) 1099-K that don't belong to you in the comment box for Step 1.
• In addition, if you shared/leased your card terminal with/to the business(es) that received the income, complete Step 3.
• If any other error was found (e.g. the amount on the Form 1099-K is incorrect), identify the error and provide the corrected information in
the comment box for Step 1.
• If you received a Form 1099-K from any Filer not listed above, enter the Filer’s Name and Filer’s Federal ID Number (if known) in the
table above or return a copy of the Form 1099-K with this worksheet.
• If the listed Merchant Category Code (MCC) in column 3 of the table above is not representative of your business' primary industry,
indicate so in the comment box for Step 1 and describe your business' primary industry. Additionally, inform your merchant acquirer
that your MCC classification requires change.
Comments for Step 1

Step 2 - Provide dollar estimates of your gross sales below in order to allow us to better understand your business. This may help
explain why the portion of your gross receipts from card sales and other Form 1099-K reportable transactions is higher than expected. If
you are a sole proprietor and filed more than one Schedule C for this tax year, provide the sum of the below amounts across all of your
businesses.
2a. Estimated gross sales from online, phone, and/or catalogue

$

2b. Estimated gross sales from gift cards

$

2c. Estimated gross sales from lottery tickets

$

2d. Estimated total number of authorized purchase transactions (available on your merchant acquirer statements)
Comments for Step 2

Catalog Number 59955K

For Paperwork Reduction Act Notice, see page 3.

Form 14420 (10-2012)

Page 2 of 3
Taxpayer name

Taxpayer Identification Number

Step 3 - If you shared your card terminal(s) with other person or businesses at any time during the tax year, complete the section below
• List the names, identification number and dollar amount of payment card receipts attributable to these persons or businesses in the
table below and indicate whether or not you filed a Form 1099 for these businesses.
• Provide a brief explanation of how these businesses are related to your own in the comment box for Step 3.
• If you filed more than four Forms 1099 for other businesses, provide details on a separate sheet.
Name of Person or Business

Taxpayer
Merchant Card Receipts
Identification
Number (SSN or EIN)

Did you file a Form 1099
showing these receipts for this
person or business

$

Yes

No

$

Yes

No

$

Yes

No

$

Yes

No

Yes

No

Comments for Step 3

Step 4 - Was sales tax included in the Gross Receipts line reported on your tax return?
Comments for Step 4

Step 5 - In the comment box below (or attach a separate sheet) please provide any other information to explain why the gross receipts
reported on your tax return are lower than expected.
Comments for Step 5

Catalog Number 59955K

Form 14420 (10-2012)

Page 3 of 3

Paperwork Reduction Act Notice
We ask for the information on this form to carry out the Internal Revenue laws of the United States. Providing this information is
voluntary. We need it to ensure that you are complying with these laws and to allow us to figure and collect the right amount of tax
You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form
displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents
may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential,
as required by section 6103.
The time needed to complete and file this form will vary depending on individual circumstances. The estimated average time is:
Recordkeeping No additional time beyond that required to prepare the tax return
Learning about the law or the form 2-4 hrs
Preparing, copying and sending the form to the IRS 3-6 hrs
If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler, we would be happy
to hear from you. You can write to the
Internal Revenue Service,
Tax Products Coordinating Committee,
SE:W:CAR:MP:T:T:SP,
1111 Constitution Ave. NW, IR-6526,
Washington, DC 20224

Catalog Number 59955K

Form 14420 (10-2012)