PDF document

- 1 -

                                    Attention: 

Copy A of this form is provided for informational purposes only. Copy A appears in red, 
similar to the official IRS form. The official printed version of Copy A of this IRS form is 
scannable, but the online version of it, printed from this website, is not. Do not print and file 
copy A downloaded from this website; a penalty may be imposed for filing with the IRS 
information return forms that can’t be scanned. See part O in the current General 
Instructions for Certain Information Returns, available at www.irs.gov/form1099, for more 
information about penalties.

Please note that Copy B and other copies of this form, which appear in black, may be 
downloaded and printed and used to satisfy the requirement to provide the information to 
the recipient.

To order official IRS information returns, which include a scannable Copy A for filing with 
the IRS and all other applicable copies of the form, visit www.IRS.gov/orderforms. Click on 
Employer and Information Returns, and we’ll mail you the forms you request and their 
instructions, as well as any publications you may order.

Information returns may also be filed electronically using the IRS Filing Information Returns 
Electronically (FIRE) system (visit www.IRS.gov/FIRE) or the IRS Affordable Care Act 
Information Returns (AIR) program (visit www.IRS.gov/AIR).

See IRS Publications 1141, 1167, and 1179 for more information about printing these tax 
forms.

- 2 -

Enlarge image

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
Abandonment of
2021 Secured Property
Form 1099-A
1 Date of lender’s acquisition or 2 Balance of principal Copy A
LENDER’S TIN BORROWER’S TIN knowledge of abandonment outstanding For
$ Internal Revenue
BORROWER’S name 3 4 Fair market value of property Service Center
File with Form 1096.
$ For Privacy Act
Street address (including apt. no.) 5 Check if the borrower was personally liable for repayment of and Paperwork
the debt . . . . . . . . . . . . ▶ Reduction Act
Notice, see the
City or town, state or province, country, and ZIP or foreign postal code 6 Description of property 2021 General
Instructions for
Certain
Account number (see instructions) Information
Returns.
Form 1099-A Cat. No. 14412G www.irs.gov/Form1099A Department of the Treasury - Internal Revenue Service
Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page

- 3 -

Enlarge image

                                                     CORRECTED (if checked)
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 
                                                                                                                                         Abandonment of 
                                                                                                                    2021                 Secured Property
                                                                                                                    Form 1099-A
                                                                                1 Date of lender’s acquisition or 2 Balance of principal          Copy B
LENDER’S TIN                          BORROWER’S TIN                             knowledge of abandonment           outstanding                   For Borrower
                                                                                                                  $                               This is important tax 
BORROWER’S name                                                                 3                                 4 Fair market value of property information and is being 
                                                                                                                                                  furnished to the IRS. If 
                                                                                                                                                  you are required to file a 
                                                                                                                  $                               return, a negligence 
Street address (including apt. no.)                                             5 If checked, the borrower was personally liable for repayment    penalty or other 
                                                                                                                                         ▶        sanction may be 
                                                                                 of the debt . . .        .       . . .  . .    .  .              imposed on you if 
City or town, state or province, country, and ZIP or foreign postal code        6 Description of property                                         taxable income results 
                                                                                                                                                  from this transaction 
                                                                                                                                                  and the IRS determines 
Account number (see instructions)                                                                                                                 that it has not been 
                                                                                                                                                  reported.
Form  1099-A    (keep for your records)                                         www.irs.gov/Form1099A               Department of the Treasury - Internal Revenue Service

- 4 -

Enlarge image

Instructions for Borrower
Certain lenders who acquire an interest in property that was security for a loan Box 1. For a lender’s acquisition of property that was security for a loan, the
or who have reason to know that such property has been abandoned must date shown is generally the earlier of the date title was transferred to the lender
provide you with this statement. You may have reportable income or loss or the date possession and the burdens and benefits of ownership were
because of such acquisition or abandonment. Gain or loss from an acquisition is transferred to the lender. This may be the date of a foreclosure or execution sale
generally measured by the difference between your adjusted basis in the or the date your right of redemption or objection expired. For an abandonment,
property and the amount of your debt canceled in exchange for the property or, the date shown is the date on which the lender first knew or had reason to know
if greater, the sale proceeds. If you abandoned the property, you may have that the property was abandoned or the date of a foreclosure, execution, or
income from the discharge of indebtedness in the amount of the unpaid balance similar sale.
of your canceled debt. The tax consequences of abandoning property depend Box 2. Shows the debt (principal only) owed to the lender on the loan when the
on whether or not you were personally liable for the debt. Losses on acquisitions interest in the property was acquired by the lender or on the date the lender first
or abandonments of property held for personal use are not deductible. See Pub. knew or had reason to know that the property was abandoned.
4681 for information about your tax consequences. Box 3. Reserved for future use.
Property means any real property (such as a personal residence), any Box 4. Shows the fair market value of the property. If the amount in box 4 is less
intangible property, and tangible personal property that is held for investment or than the amount in box 2, and your debt is canceled, you may have cancellation
used in a trade or business. of debt income. If the property was your main home, see Pub. 523 to figure any
If you borrowed money on this property with someone else, each of you taxable gain or ordinary income.
should receive this statement. Box 5. Shows whether you were personally liable for repayment of the debt
Borrower’s taxpayer identification number (TIN). For your protection, this when the debt was created or, if modified, when it was last modified.
form may show only the last four digits of your TIN (social security number Box 6. Shows the description of the property acquired by the lender or
(SSN), individual taxpayer identification number (ITIN), adoption taxpayer abandoned by you. If “CCC” is shown, the form indicates the amount of any
identification number (ATIN), or employer identification number (EIN)). However, Commodity Credit Corporation loan outstanding when you forfeited your
the issuer has reported your complete TIN to the IRS. commodity.
Account number. May show an account or other unique number the lender Future developments. For the latest information about developments related to
assigned to distinguish your account. Form 1099-A and its instructions, such as legislation enacted after they were
published, go to www.irs.gov/Form1099A.

- 5 -

Enlarge image

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
Abandonment of
2021 Secured Property
Form 1099-A
1 Date of lender’s acquisition or 2 Balance of principal Copy C
LENDER’S TIN BORROWER’S TIN knowledge of abandonment outstanding For Lender
$
BORROWER’S name 3 4 Fair market value of property
For Privacy Act
and Paperwork
$ Reduction Act
Street address (including apt. no.) 5 Check if the borrower was personally liable for repayment of Notice, see the
the debt . . . . . . . . . . . . ▶ 2021 General
Instructions for
City or town, state or province, country, and ZIP or foreign postal code 6 Description of property Certain
Information
Returns.
Account number (see instructions)

Form 1099-A www.irs.gov/Form1099A Department of the Treasury - Internal Revenue Service

- 6 -

Enlarge image

Instructions for Lender
To complete Form 1099-A, use:                             File Copy A of this form with the IRS by February 28, 2022. 
• The 2021 General Instructions for Certain Information   If you file electronically, the due date is March 31, 2022. To file 
Returns, and                                              electronically, you must have software that generates a file 
                                                          according to the specifications in Pub. 1220. The IRS does not 
• The 2021 Instructions for Forms 1099-A and 1099-C.      provide a fill-in form option for Copy A.
To order these instructions and additional forms, go to   Need help? If you have questions about reporting on Form 
www.irs.gov/Form1099A.                                    1099-A, call the information reporting customer service site 
Caution: Because paper forms are scanned during           toll free at 866-455-7438 or 304-263-8700 (not toll free). 
processing, you cannot file Forms 1096, 1097, 1098, 1099, Persons with a hearing or speech disability with access to 
3921, or 5498 that you print from the IRS website.        TTY/TDD equipment can call 304-579-4827 (not toll free).
Due dates. Furnish Copy B of this form to the borrower by 
January 31, 2022.

PDF file checksum: 1507711822

(Plugin #1/8.13/12.0)