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Enter payer, recipient, original issue discount, state, and delivery information. Review the official PDF preview before submitting the form.

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Tax Year
Payer's Information
Payer's Address
Recipient's Information
Recipient’s Address
Original Issue Discount
2nd TIN not.
FATCA Filing Requirement
$
$
$
$
$
$
$
$
$
$
$
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Tax Year 2025
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