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PAYER'S name, street address, city or town, state or province, country, 1 Original issue discount for OMB No.1545-0117
ZIP or foreign postal code, and tel€phone no. the year

U.S. Treasury $ 8ss00.00

,.* 1099-OlD Original lssue
1111 Constitution Ave. NW
WashingLon, DC 20224 (Rev. October 2019)
Discount
2 Other periodic interest
202-622-2000
For calendar year

$ 20 21
PAYER'S TIN RECIPIENT'S TIN 3 Early withdrawal penalty 4 Federal income tax withheld
Copy A
52-0907065 00-0000000 s $
5 Market discount 6 Acquisition premium
For
lntemal Revenue
RECIPIENT'S name $ $ Service Center
7 Description
ABC Company, LLC
Vehicle File with Form 1096.
Street address (including apt. no.)

100 Fake Street For Privacy Act

and Paperwork
City or town, state or province, country, and ZIP or foreign postal code 8 Original issue discount on 9 lnvestment expenses
U.S. Treasury obligations Reduction Act
Nowhere, US 100200 Notice, see the
$ 62000.00 $ current Genera!
FATCA filing 10 Bond premium 11 Tax-exempt OID
requirement lnstructions for
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lnformation
Account number (see instructions) 2nd TlN not 12 Stat( 13 State identification no. 14 State tax withheld
Retums,
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Porm 1099-OlD 6ev. 1o-201s) Cat. No.14421Fl www.irs.gov/Form1099OlD Department of the Treasury - lntemal Revenue Service

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