PAYER

HSBC BANK USA, N.A. OMB NO. 1545-0112

ONE HSBC CENTER
BUFFALO NEW YORK 14240 2009 FORM 1099-INT
TEL NO. 1-800-975-HSBC INTEREST INCOME
FEDERAL ID NO. 20-1177241 Department of the Treasury
THIS IS IMPORTANT TAX INFORMATION AND IS BEING FURNISHED TO THE INTERNAL Internal Revenue Services
REVENUE SERVICE. IF YOUARE REQUIRED TO FILE A RETURN, A NEGLIGENCE PENALTY
OR OTHER SANCTION MAY BE IMPOSED ON YOU IF THIS INCOME IS TAXABLE AND THE
Copy B,
INTERNAL REVENUE SERVICE DETERMINES THAT IT HAS NOT BEEN REPORTED.
For Recipient
24-00976 0191477-01

1. INTEREST INCOME
NOT INCLUDED IN BOX 3

$30.35
SHAWN PATRICK TIERNEY
2. EARLY WITHDRAWAL PENALTY
681 COUNTY ROUTE 54 LOT 60
PENNELLVILLE NY 13132-3220
$0.00

3. INTEREST ON U.S. SAVINGS

BONDS AND TREAS. OBLIGATIONS

$0.00

RECIPIENT'S 4. FEDERAL INCOME TAX

IDENTIFICATION NUMBER WITHHELD

079-60-7826 $0.00

DETAILS OF INTEREST PAID, INTEREST PENALTIES AND INTEREST WITHHELD

TYPE OF ACCOUNT ACCT/ TRANSACTION NO. INTEREST INCOME EARLY INTEREST ON U.S. FEDERAL
STATUS/ NOT INCLUDED IN WITHDRAWAL SAVINGS BONDS INCOME
PAYEE NAME LINE 1 DATE BOX 3 PENALTY AND TREAS. TAX
PAYEE NAME LINE 2 OBLIGATIONS WITHHELD

ONLINE SAVINGS 976-94510-0 00976 OPEN $30.35

SHAWN PATRICK TIERNEY

TOTALS $30.35 $0.00 $0.00 $0.00