Your Artificial Person Example Patrick Devine, Esq.: 1099-C Copy A

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8585 VOID CORRECTED

CREDITOR’S name, street address, city, state, ZIP code, and telephone no. 1 Date canceled OMB No. 1545-1424
Your Artificial Person; example Patrick Devine, esq.
2 Amount of debt canceled
Cancellation
$ Monthly Statement amount
3 Interest if included in box 2
2009 of Debt
$ Form 1099-C
CREDITOR’S federal identification number DEBTOR’S identification number 4 Debt description Copy A
SS Number EIN
For
DEBTOR’S name Internal Revenue
Banks name you have checking account or other card acc. with Service Center
File with Form 1096.
Street address (including apt. no.) 5 Was borrower personally liable for repayment of the debt? For Privacy Act and
Paperwork Reduction
(Quasi Trustee should have been the one
Act Notice, see the
City, state, and ZIP code for he is the one who gets the borrower's copy) 2009 General
Yes No Instructions for
Forms 1099, 1098,
Account number (see instructions) 6 Check for bankruptcy 7 Fair market value of property 3921, 3922, 5498,
Bank Checking account or credit card number
$ and W-2G.
Form 1099-C Cat. No. 26280W Department of the Treasury - Internal Revenue Service
Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page

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