CORRECTED

pnYEn S na"r", itret address, city or town, province or state, country, ZIP or foreign postal code, and telephone no.
1 Rents

OMB No. 1545-01 15

$
2 Royahies

2@13
rorm 1GI9-MISG
4 Federal income tax withheld

Miscellaneous lncome

$
3 Other income

$
PAYER'S tederal identification numbet RECIPIENT'S idontification number

s
6
Medical and heatth care Payments

Gopy 2
To be filed

5 Fishing boat proceeds

with
$ $
8 Subsiitute payments in lieu o dMdends or intsrest

RECIPIENT'S name

7 Nonemptoyee compensation

recipient's state income tax return, when required.

Street addross (including apt' no.)

$
Payer made direct sales of

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

10 Crop insurance proceeds

$5,000 or more of consumer products io a buye (recioient) for resala) L-J

s
12 Foreign GtNrtry

ll FoYeign ta( paid $

Account number (see instructions)
13 Excess golden paraciute

U.S. Possessian

14 Gross proceds paid io an

payments

attomey

$
15a Section 409A defenals

$
17 State/Payer's state no. 18 State income

15b Section 4094 income

16 State tax withheld

$ $
Form

s
www.irs.govllorml 099misc

$ $
Department of the Treasury - lntemal Revenue Service