2011 Form 1099-C, Cancellation of Debt

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

The CREDITOR'S name, street address, city, state and ZIP code field has the following information Birch Bank, 76 Spruce Lane, Treetown, KS 00000.
The CREDITOR'S federal identification number field shows an identification number of 10-7890123.
The DEBTOR'S identification number field shows an identification number of 234-00-7890.
The DEBTOR'S name, Street address (including apt. no.), and City, state, and ZIP code fields show John and Mary Elm, 11 Siberian Street, Treetown, KS 00000.
The Account number (see instructions) field shows 505050.
Box 1, Date canceled shows 3-1-2011.
Box 2, Amount of debt canceled shows $25,000.00.
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 $290,000.00.