Form 1099

FORM 1099 — INFORMATION RETURN

Payer

Recipient

Taxpayer Identification Number (Provide one)

Enter the recipient's identifying number. Provide only one: Social Security Number (SSN) or Employer Identification Number (EIN).

Recipient Entity Type

Indicate the recipient's entity classification by checking the appropriate box. Check only one box that best describes the recipient.

Payment and Withholding — Boxes

Enter the amounts paid to the recipient during the calendar year. Amounts should be reported in U.S. dollars. Use cents if applicable.

State Information

Additional Information

Certification

Under penalties of perjury, the payer or authorized preparer certifies that the information reported on this Form 1099 is true, correct, and complete to the best of the signer's knowledge and that the amounts reported are based on the payer's records for the tax year identified above.

Specifically, the signer certifies under penalty of perjury:

1. The payer has reviewed its records and affirms that the payment amounts reported herein were paid to the named recipient during the calendar year specified and are correctly characterized by the boxes on this form.
2. The taxpayer identification number provided for the recipient is accurate to the best of the payer's knowledge and that backup withholding has been applied and reported where required.
3. The payer acknowledges that intentional misstatement of material facts on this form may subject the signer to civil and criminal penalties under applicable federal and state law.

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