CORRECTED (if checked)

PAYER’S name, street address, city or town, state or province, country, ZIP Payer’s RTN (optional) OMB No. 1545-0112
or foreign postal code, and telephone no.

Interest
Green Dot Bank
1675 No. Freedom Blvd. 1 Interest income
2020
21 Income
Provo, UT 84604
$ 16.43 Form 1099-INT
2 Early withdrawal penalty
Copy B
PAYER’S TIN RECIPIENT’S TIN $ 0
For Recipient
3 Interest on U.S. Savings Bonds and Treas. obligations
87-0331019 *****2702
$ 0
RECIPIENT’S name, Street address (including apt. no.), City or town, state 4 Federal income tax withheld 5 Investment expenses This is important tax
or province, country, and ZIP or foreign postal code information and is
$ 0 $ 0
being furnished to the
Felicia , Brown 6 Foreign tax paid 7 Foreign country or U.S. possession IRS. If you are
3017 W 72nd St, Apt 3 $ 0 required to file a
Davenport IA United States 52806-1044 8 Tax-exempt interest 9 Specified private activity bond return, a negligence
interest penalty or other
sanction may be
$ 0 $ 0 imposed on you if
10 Market discount 11 Bond premium this income is
taxable and the IRS
determines that it has
FATCA filing $ 0 $ 0 not been reported.
requirement
12 Bond premium on Treasury obligations 13 Bond premium on tax-exempt bond
$ 0 $ 0
Account number (see instructions) 14 Tax-exempt and tax credit 15 State 16 State identification no. 17 State tax withheld
bond CUSIP no.
399360524054 $ 0
$
Form 1099-INT (keep for your records) www.irs.gov/Form1099INT Department of the Treasury - Internal Revenue Service