8080 VOID CORRECTED

LENDER’S name, street address, city or town, state or province, country, ZIP or OMB No. 1545-0877
foreign postal code, and telephone no.
Acquisition or
United States Treasury 2021 Abandonment of
Secured Property
1111 Constitution Ave NW
Form 1099-A
Washington, DC 20224 1 Date of lender’s acquisition or 2 Balance of principal Copy A
knowledge of abandonment outstanding
LENDER’S TIN BORROWER’S TIN
The date you give For
52-0907065 YOUR SSN 1099A to Trustee $ total amount of Purchase Internal Revenue
BORROWER’S name 3 4 Fair market value of property Service Center
File with Form 1096.
John-Henry:Doe (your beneficiary name) total amount of Purchase
$ For Privacy Act
Street address (including apt. no.) 5 Check if the borrower was personally liable for repayment of and Paperwork
Your INFO the debt . . . . . . DO. NOT . CHECK!!!
. . . . ▶
Reduction Act
Notice, see the
City or town, state or province, country, and ZIP or foreign postal code 6 Description of property 2021 General
Your INFO (right out the full state, no abbreviations) Describe property you are buying. Instructions for
Certain
Account number (see instructions) Information
The account # you are paying, or PO Number from Dealership EX. GMC Yukon VIN # 12345678910 Returns.
1099-A
Form Cat. No. 14412G www.irs.gov/Form1099A Department of the Treasury - Internal Revenue Service
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