1099 Form

FORM 1099 — INFORMATION RETURN

PAYER

Payer's name:

RECIPIENT (TAXPAYER)

Recipient's name:

ENTITY TYPE

Select the recipient's federal tax classification (check all that apply):

Individual/Sole Proprietor or Single-member LLC

C Corporation

S Corporation

Partnership

Trust/Estate

LLC

Other (describe below)

AMOUNTS (ENTER IN U.S. DOLLARS)

Box 1 — Nonemployee compensation:

Box 2 — Royalties:

Box 3 — Other income:

Box 4 — Federal income tax withheld:

Box 5 — Fishing boat proceeds:

Box 6 — Medical and health care payments:

Box 7 — Payer made direct sales of $5,000 or more:

STATE TAX INFORMATION

State tax withheld:

State/Payer's state no.:

State income:

ADDITIONAL INFORMATION

CERTIFICATION

By signing below, under penalties of perjury, I certify the following:

1. That the taxpayer identification number shown on this form is correct to the best of my knowledge and belief.
2. That I am not subject to backup withholding under applicable federal tax law, or that I have been notified that I am subject to backup withholding and have provided the appropriate notification to the payer where required.
3. That I am a U.S. person (including a U.S. resident alien) for federal tax purposes, or that I otherwise meet the conditions for reporting as required by law.
4. That the amounts reported on this form are true, accurate, and complete to the best of my knowledge and reflect all reportable payments required under federal law.

I hereby attest to the foregoing certifications and understand that false statements may be subject to penalties under federal law.

Sign Now