CAPITAL ONE N.A.

PO BOX 30249
SALT LAKE CITY, UT 84130-0249

LISA SMITH
7831 RUSH ROSE DR UNIT 309 309 For questions please call: 1-888-464-0727
CARLSBAD, CA 92009

CORRECTED (if checked)

PAYER'S name, street address, city or town, state or province, country, Payer's RTN (optional) OMB No. 1545-0112
ZIP or foreign postal code, and telephone no.
CAPITAL ONE N.A.
1680 CAPITAL ONE DR
MCLEAN, VA 22102
1 Interest income
$3,935.76 2019 Interest Income
2 Early withdrawal penalty

Form 1099-INT
3 Interest on U.S. Savings Bonds and Treas. obligations Copy B
PAYER'S TIN RECIPIENT'S TIN
72-0210640 ***-**-1493 For Recipient
RECIPIENT'S name, street address, city or town, state or province, 4 Federal income tax withheld 5 Investment expenses This is important tax
country, and ZIP or foreign postal code information and is
being furnished to the
LISA SMITH
IRS. If you are
7831 RUSH ROSE DR UNIT 309 309 6 Foreign tax paid 7 Foreign country or U.S. possession
required to file a return,
CARLSBAD, CA 92009
a negligence penalty or
8 Tax-exempt interest 9 Specified private activity bond interest other sanction may be
imposed on you if this
income is taxable and
10 Market discount 11 Bond premium the IRS determines that
it has not been reported.
12 Bond premium on Treasury obligations 13 Bond premium on tax-exempt bond

Account number (see instructions) FATCA filing 14 Tax-exempt and tax credit bond 15 State 16 State identification no. 17 State tax withheld
CUSIP no.
See Detail Below requirement CA 800-3211-3
Form 1099-INT (keep for your records) www.irs.gov/Form1099INT Department of the Treasury - Internal Revenue Service

See Details

PRODUCT ACCOUNT INTEREST EARLY W/DRAWAL INTEREST ON FED INCOME

DESCRIPTION NUMBER INCOME PENALTY U.S. BONDS TAX WITHHELD
CD ****3864 $3,935.76
$3,935.76

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1099-INT Instructions for Recipient
The information provided may be different for covered and noncovered securities. For a Box 10. For a taxable or tax-exempt covered security, if you made an election under
description of covered securities, see the Instructions for Form 8949. For a taxable covered section 1278(b) to include market discount in income as it accrues and you notified your
security acquired at a premium, unless you notified the payer in writing in accordance with payer of the election in writing in accordance with Regulations section 1.6045-1(n)(5),
Regulations section 1.6045-1(n)(5) that you did not want to amortize the premium under shows the market discount that accrued on the debt instrument during the year while held
section 171, or for a tax-exempt covered security acquired at a premium, your payer by you, unless it was reported on Form 1099-OID. For a taxable or tax-exempt covered
generally must report either (1) a net amount of interest that reflects the offset of the security acquired on or after January 1, 2015, accrued market discount will be calculated
amount of interest paid to you by the amount of premium amortization allocable to the on a constant yield basis unless you notified your payer in writing in accordance with
payment(s), or (2) a gross amount for both the interest paid to you and the premium Regulations section 1.6045-1(n)(5) that you did not want to make a constant yield election
amortization allocable to the payment(s). If you did notify your payer that you did not want for market discount under section 1276(b). Report the accrued market discount on your
to amortize the premium on a taxable covered security, then your payer will only report the income tax return as directed in the Instructions for Form 1040. Market discount on a
gross amount of interest paid to you. For a noncovered security acquired at a premium, tax-exempt security is includible in taxable income as interest income.
your payer is only required to report the gross amount of interest paid to you. Box 11. For a taxable covered security (other than a U.S. Treasury obligation), shows the
Recipient's taxpayer identification number (TIN). For your protection, this form may show amount of premium amortization allocable to the interest payment(s), unless you notified
only the last four digits of your TIN (social security number (SSN), individual taxpayer the payer in writing in accordance with Regulations section 1.6045-1(n)(5) that you did not
identification number (ITIN), adoption taxpayer identification number (ATIN), or employer want to amortize bond premium under section 171. If an amount is reported in this box,
identification number (EIN)). However, the issuer has reported your complete TIN to the see the Instructions for Form 1040 (Schedule B) to determine the net amount of interest
IRS. includible in income on Form 1040 with respect to the security. If an amount is not
FATCA filing requirement. If the FATCA filing requirement box is checked, the payer is reported in this box for a taxable covered security acquired at a premium and the payer is
reporting on this Form 1099 to satisfy its chapter 4 account reporting requirement. You reporting premium amortization, the payer has reported a net amount of interest in box 1. If
also may have a filing requirement. See the Instructions for Form 8938. the amount in box 11 is greater than the amount of interest paid on the covered security,
Account number. May show an account or other unique number the payer assigned to see Regulations section 1.171-2(a)(4).
distinguish your account. Box 12. For a U.S. Treasury obligation that is a covered security, shows the amount of
Box 1. Shows taxable interest paid to you during the calendar year by the payer. premium amortization allocable to the interest payment(s), unless you notified the payer in
This does not include interest shown in box 3. May also show the total amount of the writing in accordance with Regulations section 1.6045-1(n)(5) that you did not want to
credits from clean renewable energy bonds, new clean renewable energy bonds, qualified amortize bond premium under section 171. If an amount is reported in this box, see the
energy conservation bonds, qualified zone academy bonds, qualified school construction Instructions for Form 1040 (Schedule B) to determine the net amount of interest includible
bonds, and build America bonds that must be included in your interest income. These in income on Form 1040 with respect to the U.S. Treasury obligation. If an amount is not
amounts were treated as paid to you during 2019 on the credit allowance dates (March 15, reported in this box for a U.S. Treasury obligation that is a covered security acquired at a
June 15, September 15, and December 15). For more information, see Form 8912. See premium and the payer is reporting premium amortization, the payer has reported a net
the instructions above for a taxable covered security acquired at a premium. amount of interest in box 3. If the amount in box 12 is greater than the amount of interest
Box 2. Shows interest or principal forfeited because of early withdrawal of time savings. paid on the U.S. Treasury obligation, see Regulations section 1.171-2(a)(4).
You may deduct this amount to figure your adjusted gross income on your income tax Box 13. For a tax-exempt covered security, shows the amount of premium amortization
return. See the Instructions for Form 1040 to see where to take the deduction. allocable to the interest payment(s). If an amount is reported in this box, see Pub. 550 to
Box 3. Shows interest on U.S. Savings Bonds, Treasury bills, Treasury bonds, and Treasury determine the net amount of tax-exempt interest reportable on Form 1040. If an amount is
notes. This may or may not all be taxable. See Pub. 550. This interest is exempt from state not reported in this box for a tax-exempt covered security acquired at a premium, the payer
and local income taxes. This interest is not included in box 1. See the instructions above for has reported a net amount of interest in box 8 or 9, whichever is applicable. If the amount
a taxable covered security acquired at a premium. in box 13 is greater than the amount of interest paid on the tax-exempt covered security,
Box 4. Shows backup withholding. Generally, a payer must backup withhold if you did not the excess is a nondeductible loss. See Regulations section 1.171-2(a)(4)(ii).
furnish your taxpayer identification number (TIN) or you did not furnish the correct TIN to Box 14. Shows CUSIP number(s) for tax-exempt bond(s) on which tax-exempt interest was
the payer. See Form W-9. Include this amount on your income tax return as tax withheld. paid, or tax credit bond(s) on which taxable interest was paid or tax credit was allowed, to
Box 5. Any amount shown is your share of investment expenses of a singleclass REMIC. you during the calendar year. If blank, no CUSIP number was issued for the bond(s).
This amount is included in box 1. Boxes 15-17. State tax withheld reporting boxes.
Box 6. Shows foreign tax paid. You may be able to claim this tax as a deduction or a credit Nominees. If this form includes amounts belonging to another person(s), you are considered
on your Form 1040. See your Form 1040 instructions. a nominee recipient. Complete a Form 1099-INT for each of the other owners showing the
Box 7. Shows the country or U.S. possession to which the foreign tax was paid. income allocable to each. File Copy A of the form with the IRS. Furnish Copy B to each
Box 8. Shows tax-exempt interest paid to you during the calendar year by the payer. See owner. List yourself as the "payer" and the other owner(s) as the "recipient." File Form(s)
how to report this amount in the Instructions for Form 1040. This amount may be subject 1099-INT with Form 1096 with the Internal Revenue Service Center for your area. On
to backup withholding. See Box 4 above. See the instructions above for a tax-exempt Form 1096 list yourself as the "filer." A spouse is not required to file a nominee return to
covered security acquired at a premium. show amounts owned by the other spouse.
Box 9. Shows tax-exempt interest subject to the alternative minimum tax. This amount is Future developments. For the latest information about developments related to Form
included in box 8. See the Instructions for Form 6251. See the instructions above for a 1099-INT and its instructions, such as legislation enacted after they were published, go to
tax-exempt covered security acquired at a premium. www.irs.gov/Form1099INT.

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