5050                             VOID                      CORRECTED
FORM 1097-BTC ISSUER’S name, street address, city or town, state or      1    Total                    OMB No. 1545-2197
province, country, ZIP or foreign postal code, and telephone no.
                                                                                                    Form 1097-BTC
                                                                         $
                                                                         2a  Code                      (Rev. December 2019) Bond 
                                                                                                       For calendar year    Tax 
                                                                                                            20
                                                                         2b  Unique identifier                              Credit

FORM 1097-BTC ISSUER’S TIN            RECIPIENT’S TIN
                                                                         3    Bond type           4

RECIPIENT’S name                                                                                                            Copy A
                                                                         5a  January              5b  February              For 
                                                                         $                        $                         Internal Revenue 
Street address (including apt. no.)                                      5c  March                5d  April                 Service Center
                                                                         $                        $                         File with Form 1096.
                                                                         5e  May                  5f   June
City or town, state or province, country, and ZIP or foreign postal code $                        $ 
                                                                         5g  July                 5h  August                For Privacy Act 
                                                                         $                        $                         and Paperwork 
 Form 1097-BTC issuer is (check one):                                    5i   September           5j   October              Reduction Act 
                                                                                                                            Notice, see the 
                                                                         $                        $                         current General 
     Issuer of bond or its agent filing current year                     5k  November             5l   December             Instructions for 
     Form 1097-BTC for credit being reported                                                                                Certain Information 
                                                                         $                        $ 
     An entity or a person that received or should have received         6    Comments                                      Returns.
     a current year Form 1097-BTC and is distributing part or all 
     of that credit to others

Form 1097-BTC (Rev. 12-2019)          Cat. No. 54293T                     www.irs.gov/Form1097BTC  Department of the Treasury - Internal Revenue Service
Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page

                                                                CORRECTED (if checked)
FORM 1097-BTC ISSUER’S name, street address, city or town, state or      1    Total                    OMB No. 1545-2197
province, country, ZIP or foreign postal code, and telephone no.
                                                                                                    Form 1097-BTC
                                                                         $
                                                                         2a  Code                      (Rev. December 2019) Bond 
                                                                                                       For calendar year    Tax 
                                                                                                            20
                                                                         2b  Unique identifier                              Credit

FORM 1097-BTC ISSUER’S TIN          RECIPIENT’S TIN
                                                                         3    Bond type           4

RECIPIENT’S name                                                                                                            Copy B
                                                                         5a  January              5b  February              For Recipient
                                                                         $                        $ 
Street address (including apt. no.)                                      5c  March                5d  April
                                                                         $                        $                         This is important tax 
                                                                         5e  May                  5f   June                 information and is 
City or town, state or province, country, and ZIP or foreign postal code $                        $                         being furnished to the 
                                                                                                                            IRS. If you are required 
                                                                         5g  July                 5h  August                to file a return, a 
                                                                         $                        $                         negligence penalty or 
                                                                                                                            other sanction may be 
 Form 1097-BTC issuer is:                                                5i   September           5j   October              imposed on you if an 
                                                                         $                        $                         amount of tax credit 
     Issuer of bond or its agent filing current year                     5k  November             5l   December             exceeding the amount 
     Form 1097-BTC for credit being reported                                                                                reported on this form is 
                                                                         $                        $                         claimed on your 
     An entity or a person that received or should have received         6    Comments                                      income tax return. 
     a current year Form 1097-BTC and is distributing part or all 
     of that credit to others

Form 1097-BTC (Rev. 12-2019)        (keep for your records)               www.irs.gov/Form1097BTC  Department of the Treasury - Internal Revenue Service

Instructions for Recipient                                                hyphen and then an account number or other unique identifying 
                                                                          number.
Issuers of certain tax credit bonds or their agents, and recipients of 
Form 1097-BTC from the bond issuer or agent who are further               If no CUSIP number is available, the account number, or other 
distributing the credit, such as brokers, nominees, mutual funds, or      unique identifying number by which the bond transaction is tracked by 
partnerships, must report to you on at least a quarterly basis and file   the issuer, is shown in box 2b.
with the IRS annually on a separate Form 1097-BTC the amount of tax       C—CUSIP number
credit you are allowed for each month of the calendar year.               A—Account number
Recipient’s taxpayer identification number (TIN). For your                O—Any other identifier 
protection, this form may show only the last four digits of your TIN      Box 2b. Shows the unique identifier assigned by the Form 1097-BTC 
(social security number (SSN), individual taxpayer identification         issuer, limited to 39 alphanumeric characters. 
number (ITIN), adoption taxpayer identification number (ATIN), or 
employer identification number (EIN)). However, the issuer has            Box 3. Shows the codes for tax credit bonds that are reported on 
reported your complete TIN to the IRS.                                    separate Forms 1097-BTC:
        You will not receive a separate 4th quarter report. The           101—Clean renewable energy bond
        credits for the 4th quarter will be reported together with the    199—Other
▲!      annual aggregate total amount of allowable credits                Boxes 5a–5l. These boxes show the amount of the credit you are 
CAUTION furnished to you on or before the 15th day of the 2nd             allowed for the month during the calendar year.
        calendar month after the close of the calendar year.
                                                                          You may be entitled to claim a credit against your income tax 
Note: The first 3 quarters reported on the annual report are duplicative  liabilities, subject to certain limitations under section 54A(c).
amounts previously reported. You are allowed to take the credit           Additionally, clean renewable energy bond credits received from a 
amount from each quarter only once.                                       pass-through entity are limited to the income received from the pass-
The checkbox shows if the filer is the issuer of the bond or its agent,   through entity. New clean renewable energy bond and qualified 
or is an entity or a person that received or should have received this    energy conservation bond credits are limited to 70% of the credit 
form and is making a further distribution of the credit.                  amounts determined under section 54A(b); the credit reported on 
Box 1. Shows the aggregate total of credits allowed for the calendar      Form 1097-BTC is the credit amount after the 70% limit has been 
year.                                                                     applied. For more information, see Form 8912.
Box 2a. Indicates if the unique identification number is your account     Box 6. May show any additional information provided by the form 
number, the CUSIP number of the bond, or another identifier. For          issuer. 
filings of Form 1097-BTC by the issuer of the bond or its agent (as       Future developments. For the latest information about  
indicated by the first checkbox being checked), the first nine            developments related to Form 1097-BTC and its instructions, such as 
characters of the unique identifier in box 2b must be the CUSIP           legislation enacted after they were published, go to 
number, if available. For further identification, if necessary or desired www.irs.gov/Form1097BTC.
by the issuer, the CUSIP number can be followed by an optional 

                                      VOID                      CORRECTED
FORM 1097-BTC ISSUER’S name, street address, city or town, state or      1    Total                 OMB No. 1545-2197
province, country, ZIP or foreign postal code, and telephone no.
                                                                                                 Form 1097-BTC
                                                                         $
                                                                         2a  Code                   (Rev. December 2019) Bond 
                                                                                                    For calendar year    Tax 
                                                                                                        20
                                                                         2b  Unique identifier                           Credit

FORM 1097-BTC ISSUER’S TIN            RECIPIENT’S TIN
                                                                         3    Bond type        4

RECIPIENT’S name                                                                                                         Copy C
                                                                         5a  January           5b  February              For Payer
                                                                         $                     $ 
Street address (including apt. no.)                                      5c  March             5d  April
                                                                         $                     $ 
                                                                         5e  May               5f   June
City or town, state or province, country, and ZIP or foreign postal code $                     $                         For Privacy Act 
                                                                                                                         and Paperwork 
                                                                         5g  July              5h  August                Reduction Act 
                                                                         $                     $                         Notice, see the 
 Form 1097-BTC issuer is (check one):                                    5i   September        5j   October              current General 
                                                                         $                     $                         Instructions for 
                                                                                                                         Certain Information 
     Issuer of bond or its agent filing current year                     5k  November          5l   December             Returns.
     Form 1097-BTC for credit being reported
                                                                         $                     $ 
     An entity or a person that received or should have received         6    Comments
     a current year Form 1097-BTC and is distributing part or all 
     of that credit to others

Form 1097-BTC (Rev. 12-2019)                         www.irs.gov/Form1097BTC                    Department of the Treasury - Internal Revenue Service

Instructions for Payer                                         amounts for the annual reporting and explain the correction 
                                                               to the recipient; no explanation is required for the IRS filing. 
To complete Form 1097-BTC, use: 
                                                                For the report furnished to the recipient (quarterly or 
• The current General Instructions for Certain Information     annual), you may use Copy B or your own substitute 
Returns, and                                                   statement reporting all the same applicable information 
• The current Instructions for Form 1097-BTC.                  (the reporting for the first 3 quarters may be furnished 
To order these instructions and additional forms, go to        electronically). 
www.irs.gov/Form1097BTC.                                       The IRS encourages Form 1097-BTC issuers to provide 
Filing and furnishing. Furnish the information shown on        the credit information to the recipient monthly, if 
Copy B of this form to the recipient on or before the 15th     applicable, and as soon after the end of the month in which 
day of the 2nd calendar month after the close of the           a credit arises as possible.
calendar quarter in which the credit is allowed.               For filing and furnishing instructions, and to request filing 
For the first 3 quarters, report to the recipient only the     or furnishing extensions, see the current General  
amounts for the months of the applicable quarter. Box 1        Instructions for Certain Information Returns. To file 
should not be completed and box 6 is optional.                 electronically, you must have software that generates a file 
You are not required to furnish a separate report solely       according to the specifications in Pub. 1220.
for the 4th quarter because the 4th quarter amounts are        Need help? If you have questions about reporting onForm 
reported with the annual filing. For the annual filing, report 1097-BTC, call the information reportingcustomer    service 
the credits for each month in boxes 5a–5l, report the total    site toll free at 866-455-7438 or304-263-8700 (not toll 
of those amounts in box 1, and complete the rest of the        free). Persons with a hearing or speech disability with 
form as applicable. If any amounts previously furnished for    access to TTY/TDD equipment can call 304-579-4827 (not 
the first 3 quarters need to be corrected, report the correct  toll free).