2011, Form 1099–C, Cancellation of Debt

Summary: This is an example of Form 1099-C, Copy B, with the following line items filled out:

The CREDITOR'S name, street address, city, state and ZIP code field has the following information Bumble Bank, 5 Market Street, Buzztown, NJ 07000.
The CREDITOR'S federal identification number field shows an identification number of 10-7654321.
The DEBTOR'S identification number field shows an identification number of 987-00-4321.
The DEBTOR'S name, Street address (including apt. no.), and City, state, and ZIP code fields show Frank and Kathy Willow, 21 Honeytree Lane, Apt. 5B, Buzztown, NJ 07000.
The Account number (see instructions) box shows 5551212.
Box 1, Date canceled shows 12-26-2011.
Box 2, Amount of debt canceled shows $750,000.00.
Box 4, Debt description shows Home mortgage loan.
Box 5, Was borrower personally liable for repayment of the debt? shows the Yes checkbox with a checkmark.
Box 7, Fair market value of property shows $1,750,000.00.