1099 C Form

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1/4 Personal Information

Year of filing

2/4 Tax Information

Creditor Name

Creditor TIN

Creditor Phone Number

Country

Address i

Apt/Ste No

City

State

Zip Code

3/4 Certification

Debtor Name

Debtor TIN

Debtor Phone Number

Country

Address i

Apt/Ste No

City

State

Zip Code

3/4 Government Payments

Account Number

1. Date of identifiable eventi

2. Amount of Debt Dischargedi

3. Interest if Included in Box 2i

4. Debt Descriptioni

Debtor Was Personally Liable for Repayment of the Debti

6. Identifiable Event Codei

7. Fair Market Value (FMV) of Propertyi

4/4 Submit

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1099 C Form

1/4 Personal Information

2/4 Tax Information

3/4 Certification

3/4 Government Payments

4/4 Submit

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