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

ABC BANK 1212 BANKERS STREET SEATTLE, WASHINGTON 98101 (800) 555-0505
PAYER'S federal identification number RECIPIENTS identification number

1 Original issue discount for 2008'

OMS No. 1545-0117

$10000.00
2 Other periodic interest

~@08
Form

Original Issue Discount

$-03 Early withdrawal penalty

1099-010

4 Federal incDme lax withheld

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 this income is taxable and the IRS determines that it has not been reported.

98-7654321
RECIPIENTS name

123-45-6789

$ -05 Description

$9000.00

JOHN H DOE
Street address (including apt. no.)

JOHN H DOE

123 MAIN STREET

City, state, and ZIP code

HUNTINGTON BEACH, CA 92648

Account number (see instructions)

$ -0-

1001145678
rm

1099-010

(keep for your records)

Department of the Treasury - Internal Revenue Service

NAME OF THE ISSUER IF THE PAYER IS NOT THE ISSUER

ACCOUNT/LOAN NUMBER