JOSE K DOE JR. *13 Account Information For: 1525 W. 820 N. Taxpayer ID. 999-99-9999 PROVO, UT 84601 Copy B for Recipient Form 1099-INT PAGE 1 Interest Income For 2005 ________________________________________________________________________________ Box 1 Box 2 Box 4 Early FEDERAL Account Interest Withdrawal INCOME TAX Year-End Maturity Number Income Penalty WITHHELD Balance Date 001 00101 01 703.00 0.00 0.00 46,107.40 Total 703.00 0.00 0.00 46,107.40 ________________________________________________________________________________ MIAMI BANK FEDERAL ID NUMBER 12-1662166 OMB NO. 1545-0112 THIS IS IMPORTANT TAX INFORMATION AND IS BEING FURNISHED TO THE INTERNAL REVENUE SERVICE. IF YOU ARE REQUIRED TO FILE A RETURN, A NEGLIGENCE PENALTY OR OTHER SANCTION MAY BE IMPOSED ON YOU IF THIS INCOME IS TAXABLE AND THE IRS DETERMINES THAT IT HAS NOT BEEN REPORTED. Box 1. Shows interest paid to you during the calendar year by the payer. This does not include interest shown in box 3. If you receive a Form 1099-INT for interest paid on a tax-exempt obligation, see the instructions for your income tax return. Box 2. Shows interest or principal forfeited because of early withdrawal of time savings. You may deduct this amount to figure your adjusted gross income on your income tax return. See the instructions for Form 1040 to see where to take the deduction. Box 4. Shows backup withholding. Generally, a payer must backup withhold at a 28% rate if you did not furnish your taxpayer identification number(TIN) or you did not furnish the correct TIN to the payer. See FORM W-9, Request for Taxpayer Identification Number and Certification, for information on backup withholding. INCLUDE THIS AMOUNT ON YOUR INCOME TAX RETURN AS TAX WITHHELD. NOMINEES: If this form includes amounts belonging to another person(s), you are considered a nominee recipient. Complete a Form 1099-INT for each of the other owners showing the income allocable to each. File Copy A of the form with the IRS. Furnish Copy B to each owner. List yourself as the "payer" and the other owners as the "recipient." File Form(s) 1099-INT with FORM 1096, Annual Summary and Transmittal of U.S. Information Returns, with the Internal Revenue Service Center for your area. On Form 1096 list yourself as the "filer." A husband or wife is not required to file a nominee return to show amounts owned by the other. JOSE K DOE JR. *13 Account Information For: Taxpayer ID. 999-99-9999 Copy B for Recipient Form 1099-INT PAGE 2 Interest Income For 2005 ________________________________________________________________________________ Year-end balance and maturity date are not furnished to the I.R.S.