☐ CORRECTED (if checked) PAYER'S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no. Payer's RTN (optional) OMB No. 1545-0112 Orlando National Bank 9871 Disney Way Orlando, FL 32801 PAYER'S TIN 60-7654321 2021 1 Interest income 1,369.11 $ Form 1099-INT 2 Early withdrawal penalty RECIPIENT'S TIN $ 3 Interest on U.S. Savings Bonds and Treas. obligations 266-15-1966 $ Interest Income Copy B For Recipient RECIPIENT'S name Alexander T. Smith Street address (including apt. no.) 1234 Buena Vista Drive $ $ 6 Foreign tax paid $ 8 Tax-exempt interest City or town, state or province, country, and ZIP or foreign postal code $ 10 Market discount 11 Bond premium Orlando, FL 32830 FATCA filing $ requirement 4 Federal income tax withheld 5 Investment expenses 12 Bond premium on Treasury obligations 13 Bond premium on tax-exempt bond This is important tax information and is being furnished to the IRS. 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. 7 Foreign country or U.S. possession 9 Specified private activity bond interest Account number (see instructions) Form 1099-INT (keep for your records) $ $ 14 Tax-exempt and tax credit bond CUSIP no. 15 State 16 State identification no. 17 State tax withheld $ $ www.irs.gov/Form 1099INT Department of the Treasury - Internal Revenue Service a Employee's social security number 266-15-1966 b Employer identification number (EIN) 60-3456789 c Employer's name, address, and ZIP code Kissimmee Airlines, Inc. 2432 Bay Blvd. Kissimmee, FL 34741 d Control number e Employee's first name and initial Last name Alexander T. Smith 1234 Buena Vista Drive Orlando, FL 32830 OMB No. 1545-0008 Safe, accurate, FAST! Use Visit the IRS website at IRS file www.irs.gov/efile 1 Wages, tips, other compensation 65,137.00 3 Social security wages 68,409.00 5 Medicare wages and tips 68,409.00 7 Social security tips 9 Verification code Suff. 11 Nonqualified plans 2 Federal income tax withheld 6,010.00 4 Social security tax withheld 4, 241.36 6 Medicare tax withheld 991.93 8 Allocated tips 10 Dependent care benefits 13 Statutory employee 14 Other 12a See instructions for box 12 C D 3,272.00 Retirement plan Third-party sick pay 12b с d e 12c с 12d C f Employee's address and ZIP code 15 State Employer's state ID number 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name FL Form Wage and Tax W-2 Statement 2021 Copy B-To Be Filed With Employee's FEDERAL Tax Return. This information is being furnished to the Internal Revenue Service. Department of the Treasury-Internal Revenue Service