2010 Form 1099-C, Cancellation of Debt

Summary: This is an example of Form 1099-C, Copy B, with items included as described in the text. Additionally, these line items were filled out:

The CREDITOR'S name, street address, city, state and ZIP code field has the following information Goodold Bank, 54 Happy Street, Anytown, FL 00000.
The CREDITOR'S federal identification number field shows an identification number of 10–6543210.
The DEBTOR'S identification number field shows an identification number of 123-00-6789.
The DEBTOR'S name, Street address (including apt. no.), and City, state, and ZIP code fields show Nancy Oak, 360 Degree Circle, Anyplace, FL 00000.
Box 1, Date canceled shows 8-31-2010.
Box 2, Amount of debt canceled shows $40,000.00
Box 4, Debt description shows Home mortgage loan.
Box 5, Was borrower personally liable for repayment of the debt? shows Yes checkbox with a checkmark.