1099-DA

PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.

PAYER’S TIN

RECIPIENT’S TIN

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

1 Rents

2 Royalties

3 Other income

4 Federal income tax withheld

5 Fishing boat proceeds

6 Medical and health care payments

7 Payer made direct sales totaling $5,000 or more

8 Substitute payments in lieu of dividends or interest

Form 1099-DA