Unrecap. Sec. 1250 gain

VOID CORRECTED

PAYER’S name, street address, city, state, ZIP code, and telephone no. 1a Total ordinary dividends OMB No. 1545-0110

$

1b Qualified dividends

$

2a Total capital gain distr. Post-May 5 capital gain distr.

RECIPIENT’S identification

number

PAYER’S Federal identification

number

2c

Collectibles (28%) gain

Qualified 5-year gain 2d

$ $

RECIPIENT’S name Section 1202 gain 2e 2f

$

3

Street address (including apt. no.) 5 Investment expenses

City, state, and ZIP code

Noncash liquidation

distributions

Cash liquidation 9

distributions

Account number (optional) 8

$

$

2b

$ $

Nontaxable distributions

Form 1099-DIV

Dividends and

Distributions

$

9191

2nd TIN not.

Form 1099-DIV Cat. No. 14415N Department of the Treasury - Internal Revenue Service

Copy A

File with Form 1096.

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2003 General

Instructions for

Forms 1099,

1098, 5498,

and W-2G.

For

Internal Revenue

Service Center

Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page

6 7

2003

Foreign tax paid Foreign country or U.S. possession

$

$

4 Federal income tax withheld

$

$
CORRECTED (if checked)

PAYER’S name, street address, city, state, ZIP code, and telephone no.

RECIPIENT’S identification

number

PAYER’S Federal identification

number

RECIPIENT’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (optional)

Dividends and

Distributions

Form 1099-DIV (keep for your records) Department of the Treasury - Internal Revenue Service

Copy B

This is important

tax information

and is being

furnished to the

Internal Revenue

Service. If you

are required to

file a return, a

negligence

penalty or other

sanction may be

imposed on you

if this income is

taxable and the

IRS determines

that it has not

been reported.

For Recipient

Unrecap. Sec. 1250 gain

1a Total ordinary dividends OMB No. 1545-0110

$

1b Qualified dividends

$

2a Total capital gain distr. Post-May 5 capital gain distr.

2c

Collectibles (28%) gain

Qualified 5-year gain 2d

$ $

2e Section 1202 gain 2f

$

3

5 Investment expenses

Noncash liquidation

distributions

Cash liquidation 9

distributions

8

$

$

2b

$ $

Nontaxable distributions

Form 1099-DIV

$

6 7

2003

$

Foreign tax paid Foreign country or U.S. possession

$

$

4 Federal income tax withheld

$
Box 1b. Shows the portion of the amount in box 1a that may be

eligible for the new 15% or 5% capital gains rates. See the Form

1040/1040A instructions for how to determine this amount. Report

the eligible amount on line 9b, Form 1040 or 1040A.

Box 1a. Shows total ordinary dividends that are taxable. Include this

amount on line 9a of Form 1040 or 1040A. Also, report it on

Schedule B (Form 1040) or Schedule 1 (Form 1040A), if required.

Instructions to Recipients

Box 4. Shows backup withholding. For example, a payer must

backup withhold on certain payments at a 28% rate if you did not

give your taxpayer identification number to the payer. See Form

W-9, Request for Taxpayer Identification Number and Certification,

for information on backup withholding. Include this amount on your

income tax return as tax withheld.

Box 2a. Shows total capital gain distributions (long-term) from a

regulated investment company or real estate investment trust.

Report the amounts shown in boxes 2a and 2b (see below) on

Schedule D (Form 1040), line 13. But, if no amount is shown in

boxes 2c–2f and your only capital gains and losses are capital gain

distributions, you may be able to report the amounts shown in boxes

2a and 2b on lines 13a and 13b of Form 1040 (lines 10a and 10b of

Form 1040A) rather than Schedule D. See the Form 1040/1040A

instructions.

Box 2b. Shows the portion of the amount in box 2a that is post-May

5 capital gain distributions eligible for the new 15% and 5% capital

gains rates. See box 2a above for how to report this amount.

Box 2d. Shows the portion of the amount in box 2a that is

unrecaptured section 1250 gain from certain depreciable real

property. Report this amount on the Unrecaptured Section 1250

Gain Worksheet in the Schedule D instructions (Form 1040).

Box 3. Shows the part of the distribution that is nontaxable because

it is a return of your cost (or other basis). You must reduce your cost

(or other basis) by this amount for figuring gain or loss when you sell

your stock. But if you get back all your cost (or other basis), report

future nontaxable distributions as capital gains, even though this

form shows them as nontaxable. See Pub. 550, Investment Income

and Expenses.

Box 2e. Shows the portion of the amount in box 2a that is section

1202 gain from certain small business stock that may be subject to

a 50% exclusion. See the Schedule D (Form 1040) instructions.

Box 6. Shows the foreign tax you may be able to claim as a

deduction or a credit on Form 1040. See the Form 1040 instructions.

Boxes 8 and 9. Shows cash and noncash liquidation distributions.

Nominees. If this form includes amounts belonging to another

person, you are considered a nominee recipient. You must file Form

1099-DIV with the IRS for each of the other owners to show their

share of the income, and you must furnish a Form 1099-DIV to each.

A husband or wife is not required to file a nominee return to show

amounts owned by the other. See the 2003 General Instructions

for Forms 1099, 1098, 5498, and W-2G.

Box 2c. Shows the portion of the amount in box 2a that is qualified

5-year gain that may be taxed at an 8% capital gains rate. Report

this amount on Schedule D (Form 1040), line 35 (if required).

Box 5. Shows your share of expenses of a nonpublicly offered

regulated investment company, generally a nonpublicly offered

mutual fund. If you file Form 1040, you may deduct these expenses

on the “Other expenses” line on Schedule A (Form 1040) subject to

the 2% limit. This amount is included in box 1a.

Box 2f. Shows 28% rate gain from sales or exchanges of

collectibles. If required, use this amount when completing the 28%

Rate Gain Worksheet-Line 20 in the instructions for Schedule D

(Form 1040).

The amount shown may be a distribution from an employee stock

ownership plan (ESOP). Report it as a dividend on your Form

1040/1040A but treat it as a plan distribution, not as investment

income, for any other purpose.
PAYER’S name, street address, city, state, ZIP code, and telephone no.

RECIPIENT’S identification

number

PAYER’S Federal identification

number

RECIPIENT’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (optional)

Dividends and

Distributions

Form 1099-DIV Department of the Treasury - Internal Revenue Service

Copy C

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2003 General

Instructions

for Forms

1099, 1098,

5498,

and W-2G.

For Payer

VOID CORRECTED

2nd TIN not.

Unrecap. Sec. 1250 gain

1a Total ordinary dividends OMB No. 1545-0110

$

1b Qualified dividends

$

2a Total capital gain distr. Post-May 5 capital gain distr.

2c

Collectibles (28%) gain

Qualified 5-year gain 2d

$ $

2e Section 1202 gain 2f

$

3

5 Investment expenses

Noncash liquidation

distributions

Cash liquidation 9

distributions

8

$

$

2b

$ $

Nontaxable distributions

Form 1099-DIV

$

6 7

2003

Foreign tax paid Foreign country or U.S. possession

$

$

4 Federal income tax withheld

$

$
Instructions for Payers

General and specific form instructions are provided as

separate products. The products you should use for

2003 are the General Instructions for Forms 1099,

1098, 5498, and W-2G and the separate specific

instructions for each information return you file.

Specific information needed to complete this form is

given in the 2003 Instructions for Form 1099-DIV. A

chart in the general instructions gives a quick guide to

which form must be filed to report a particular

payment. To order these instructions and additional

forms, call 1-800-TAX-FORM (1-800-829-3676).

Due dates. Furnish Copy B of this form to the

recipient by February 2, 2004.

File Copy A of this form with the IRS by March 1,

2004. If you file electronically, the due date is

March 31, 2004.

Foreign dividend recipient. If the recipient of the

dividend is a nonresident alien, you may have to

withhold Federal income tax and file Form 1042-S,

Foreign Person’s U.S. Source Income Subject to

Withholding. See the Instructions for Form 1042-S

and Pub. 515, Withholding of Tax on Nonresident

Aliens and Foreign Entities.

Caution: Because the IRS processes paper forms by

machine (optical character recognition equipment), you

cannot file with the IRS Forms 1096, 1098, 1099, or

5498 that you print from the IRS website.