Request for original or




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REQUEST FOR ORIGINAL OR

CORRECTED 1099-MISC OR 1042-S TAX STATEMENT


CALENDAR REPORTING YEAR:




FORM:

1099-MISC




1042-S







NAME REPORTED ON TAX STATEMENT:




TAX IDENTIFICATION NUMBER:




IF 1099-MISC – BOX INCOME REPORTED:




(Box 1- Rent, Box 2 – Royalty, Box 3 – Participant Stipend, Box 7 – Independent Contractor)

IF 1042-S – INCOME CODE REPORTED:




(15 – Fellowship, 18 – Employee Teacher Researcher, 19 Employee Student, 16 – Independent Contractor, 10 - Royalty Industrial, 12 - Royalty Copyright, 50 - Participant Stipend)

AMOUNT REPORTED ON ORIGINAL FORM:




AMOUNT CHANGE

DECREASE




INCREASE




AMOUNT (NET OF CHANGE) TO REPORT ON CORRECTED FORM:




CURRENT MAILING ADDRESS:

Street Address




City




State




Zip Code







LOCATION AND REQUESTOR:







The corrected form is requested for the following reason:




System coding error




Tax Identification Number incorrect




Funds returned




Other




Details









FOR CENTRAL OFFICE USE ONLY:
Tax Statement corrected on: ______/______/______ Mailed on: ______/______/______
Processed By: _______________________________________


February 16


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