Attention: 

Copy A of this form is provided for informational purposes only. Copy A appears in red, 

similar to the official IRS form. The official printed version of Copy A of this IRS form is 

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copy A downloaded from this website; a penalty may be imposed for filing with the IRS 

information return forms that can’t be scanned. See part O in the current General 

Instructions for Certain Information Returns, available at www.irs.gov/form1099, for more 

information about penalties.

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forms.
 

Form 1099-DIV 

2021

Cat. No. 14415N 

Dividends and 

Distributions 

Copy A

For 

Internal Revenue 

Service Center 

Department of the Treasury - Internal Revenue Service

File with Form 1096.

OMB No. 1545-0110 

For Privacy Act 

and Paperwork 

Reduction Act 

Notice, see the 

2021 General 

Instructions for 

Certain 

Information 

Returns. 

9191 VOID CORRECTED

PAYER’S name, street address, city or town, state or province, country, ZIP 

or foreign postal code, and telephone no. 

PAYER’S TIN RECIPIENT’S TIN

RECIPIENT’S name 

Street address (including apt. no.) 

City or town, state or province, country, and ZIP or foreign postal code

FATCA filing 

requirement

Account number (see instructions) 2nd TIN not. 

1a Total ordinary dividends 

$ 

1b Qualified dividends

$ 

2a Total capital gain distr.

$ 

2b Unrecap. Sec. 1250 gain 

$ 

2c Section 1202 gain 

$ 

2d Collectibles (28%) gain 

$ 

2e Section 897 ordinary dividends

$ 

2f Section 897 capital gain 

$ 

3 Nondividend distributions 

$ 

4 Federal income tax withheld

$ 

5 Section 199A dividends

$ 

6 Investment expenses 

$ 

7 Foreign tax paid 

$ 

8 Foreign country or U.S. possession

9 Cash liquidation distributions

$ 

10 Noncash liquidation distributions

$ 

11 Exempt-interest dividends

$ 

12 Specified private activity 

bond interest dividends

$ 

13 State 14 State identification no. 15 State tax withheld

$ 

$ 

Form 1099-DIV www.irs.gov/Form1099DIV

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

Form 1099-DIV 

2021 Dividends and 

Distributions 

Copy 1

For State Tax 

Department 

Department of the Treasury - Internal Revenue Service

OMB No. 1545-0110 

VOID CORRECTED

PAYER’S name, street address, city or town, state or province, country, ZIP 

or foreign postal code, and telephone no. 

PAYER’S TIN RECIPIENT’S TIN 

RECIPIENT’S name 

Street address (including apt. no.) 

City or town, state or province, country, and ZIP or foreign postal code

FATCA filing 

requirement

Account number (see instructions) 

1a Total ordinary dividends 

$ 

1b Qualified dividends

$ 

2a Total capital gain distr.

$ 

2b Unrecap. Sec. 1250 gain 

$ 

2c Section 1202 gain 

$ 

2d Collectibles (28%) gain 

$ 

2e Section 897 ordinary dividends

$ 

2f Section 897 capital gain 

$ 

3 Nondividend distributions 

$ 

4 Federal income tax withheld

$ 

5 Section 199A dividends

$ 

6 Investment expenses 

$ 

7 Foreign tax paid 

$ 

8 Foreign country or U.S. possession

9 Cash liquidation distributions

$ 

10 Noncash liquidation distributions

$ 

11 Exempt-interest dividends

$ 

12 Specified private activity 

bond interest dividends

$ 

13 State 14 State identification no. 15 State tax withheld

$ 

$ 

Form 1099-DIV www.irs.gov/Form1099DIV
 

Form 1099-DIV 

2021 Dividends and 

Distributions 

Copy B 

For Recipient 

Department of the Treasury - Internal Revenue Service

This is important tax 

information and is 

being furnished to 

the IRS. 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. 

OMB No. 1545-0110 

CORRECTED (if checked)

PAYER’S name, street address, city or town, state or province, country, ZIP 

or foreign postal code, and telephone no. 

PAYER’S TIN RECIPIENT’S TIN

RECIPIENT’S name 

Street address (including apt. no.) 

City or town, state or province, country, and ZIP or foreign postal code

FATCA filing 

requirement

Account number (see instructions) 

1a Total ordinary dividends 

$ 

1b Qualified dividends

$ 

2a Total capital gain distr.

$ 

2b Unrecap. Sec. 1250 gain 

$ 

2c Section 1202 gain 

$ 

2d Collectibles (28%) gain 

$ 

2e Section 897 ordinary dividends

$ 

2f Section 897 capital gain 

$ 

3 Nondividend distributions 

$ 

4 Federal income tax withheld

$ 

5 Section 199A dividends

$ 

6 Investment expenses 

$ 

7 Foreign tax paid 

$ 

8 Foreign country or U.S. possession

9 Cash liquidation distributions

$ 

10 Noncash liquidation distributions

$ 

11 Exempt-interest dividends

$ 

12 Specified private activity 

bond interest dividends

$ 

13 State 14 State identification no. 15 State tax withheld

$ 

$ 

Form 1099-DIV (keep for your records) www.irs.gov/Form1099DIV
Instructions for Recipient 

Recipient’s taxpayer identification number (TIN). For your protection, this 

form may show only the last four digits of your TIN (SSN, ITIN, ATIN, or EIN). 

However, the issuer has reported your complete TIN to the IRS.

FATCA filing requirement. If the FATCA filing requirement box is checked, the 

payer is reporting on this Form 1099 to satisfy its account reporting requirement 

under chapter 4 of the Internal Revenue Code. You may also have a filing 

requirement. See the Instructions for Form 8938.

Account number. May show an account or other unique number the payer 

assigned to distinguish your account. 

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

the “Ordinary dividends” line of Form 1040 or 1040-SR. Also report it on 

Schedule B (Form 1040), if required. 

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

reduced capital gains rates. See the Instructions for Forms 1040 and 1040-SR 

for how to determine this amount and where to report. 

The amount shown may be dividends a corporation paid directly to you as a 

participant (or beneficiary of a participant) in an employee stock ownership plan 

(ESOP). Report it as a dividend on your Form 1040 or 1040-SR but treat it as a 

plan distribution, not as investment income, for any other purpose. 

Box 2a. Shows total capital gain distributions from a regulated investment

company (RIC) or real estate investment trust (REIT). See How To Report in the 

Instructions for Schedule D (Form 1040). But, if no amount is shown in boxes 

2b, 2c, 2d, and 2f and your only capital gains and losses are capital gain 

distributions, you may be able to report the amounts shown in box 2a on your 

Form 1040 or 1040-SR rather than Schedule D. See the Instructions for Forms 

1040 and 1040-SR. 

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

1250 gain from certain depreciable real property. See the Unrecaptured Section 

1250 Gain Worksheet in the Instructions for Schedule D (Form 1040). 

Box 2c. Shows the portion of the amount in box 2a that is section 1202 gain

from certain small business stock that may be subject to an exclusion. See the 

Schedule D (Form 1040) instructions. 

Box 2d. Shows the portion of the amount in box 2a that is 28% rate gain from 

sales or exchanges of collectibles. If required, use this amount when completing 

the 28% Rate Gain Worksheet in the Instructions for Schedule D (Form 1040). 

Box 2e. Shows the portion of the amount in box 1a that is section 897 gain 

attributable to disposition of U.S. real property interests (USRPI). 

Box 2f. Shows the portion of the amount in box 2a that is section 897 gain 

attributable to disposition of USRPI.

Note: Boxes 2e and 2f apply only to foreign persons and entities whose income 

maintains its character when passed through or distributed to its direct or 

indirect foreign owners or beneficiaries. It is generally treated as effectively 

connected to a trade or business within the United States. See the instructions 

for your tax return.

Box 3. Shows a return of capital. To the extent of your cost (or other basis) in 

the stock, the distribution reduces your basis and is not taxable. Any amount 

received in excess of your basis is taxable to you as capital gain. See Pub. 550.

Box 4. Shows backup withholding. A payer must backup withhold on certain 

payments if you did not give your TIN to the payer. See Form W-9 for 

information on backup withholding. Include this amount on your income tax 

return as tax withheld. 

Box 5. Shows the portion of the amount in box 1a that may be eligible for the 

20% qualified business income deduction under section 199A. See the 

instructions for Form 8995 and Form 8995-A.

Box 6. Shows your share of expenses of a nonpublicly offered RIC, generally a 

nonpublicly offered mutual fund. This amount is included in box 1a. 

Box 7. Shows the foreign tax that you may be able to claim as a deduction or a 

credit on Form 1040 or 1040-SR. See the Instructions for Forms 1040 and 1040-

SR. 

Box 8. This box should be left blank if a RIC reported the foreign tax shown in 

box 7. 

Boxes 9 and 10. Show cash and noncash liquidation distributions. 

Box 11. Shows exempt-interest dividends from a mutual fund or other RIC paid 

to you during the calendar year. See the Instructions for Forms 1040 and 1040-

SR for where to report. This amount may be subject to backup withholding. See 

Box 4 above.

Box 12. Shows exempt-interest dividends subject to the alternative minimum 

tax. This amount is included in box 11. See the Instructions for Form 6251.

Boxes 13–15. State income tax withheld reporting boxes.

Nominees. If this form includes amounts belonging to another person, you are

considered a nominee recipient. You must file Form 1099-DIV (with a Form 

1096) 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 spouse is not 

required to file a nominee return to show amounts owned by the other spouse. 

See the 2021 General Instructions for Certain Information Returns. 
 

Form 1099-DIV 

2021 Dividends and 

Distributions 

Copy 2

To be filed with 

recipient’s state 

income tax return, 

when required.

Department of the Treasury - Internal Revenue Service

OMB No. 1545-0110 

VOID CORRECTED

PAYER’S name, street address, city or town, state or province, country, ZIP 

or foreign postal code, and telephone no. 

PAYER’S TIN RECIPIENT’S TIN

RECIPIENT’S name 

Street address (including apt. no.) 

City or town, state or province, country, and ZIP or foreign postal code

FATCA filing 

requirement

Account number (see instructions) 

1a Total ordinary dividends 

$ 

1b Qualified dividends

$ 

2a Total capital gain distr.

$ 

2b Unrecap. Sec. 1250 gain 

$ 

2c Section 1202 gain 

$ 

2d Collectibles (28%) gain 

$ 

2e Section 897 ordinary dividends

$ 

2f Section 897 capital gain 

$ 

3 Nondividend distributions 

$ 

4 Federal income tax withheld

$ 

5 Section 199A dividends

$ 

6 Investment expenses 

$ 

7 Foreign tax paid 

$ 

8 Foreign country or U.S. possession

9 Cash liquidation distributions

$ 

10 Noncash liquidation distributions

$ 

11 Exempt-interest dividends

$ 

12 Specified private activity 

bond interest dividends

$ 

13 State 14 State identification no. 15 State tax withheld

$ 

$ 

Form 1099-DIV www.irs.gov/Form1099DIV
 

Form 1099-DIV 

2021 Dividends and 

Distributions 

Copy C

For Payer

Department of the Treasury - Internal Revenue Service

OMB No. 1545-0110 

For Privacy Act 

and Paperwork 

Reduction Act 

Notice, see the 

2021 General 

Instructions for 

Certain 

Information 

Returns.

VOID CORRECTED

PAYER’S name, street address, city or town, state or province, country, ZIP 

or foreign postal code, and telephone no. 

PAYER’S TIN RECIPIENT’S TIN

RECIPIENT’S name 

Street address (including apt. no.) 

City or town, state or province, country, and ZIP or foreign postal code

FATCA filing 

requirement

Account number (see instructions) 2nd TIN not. 

1a Total ordinary dividends 

$ 

1b Qualified dividends

$ 

2a Total capital gain distr.

$ 

2b Unrecap. Sec. 1250 gain 

$ 

2c Section 1202 gain 

$ 

2d Collectibles (28%) gain 

$ 

2e Section 897 ordinary dividends

$ 

2f Section 897 capital gain 

$ 

3 Nondividend distributions 

$ 

4 Federal income tax withheld

$ 

5 Section 199A dividends

$ 

6 Investment expenses 

$ 

7 Foreign tax paid 

$ 

8 Foreign country or U.S. possession

9 Cash liquidation distributions

$ 

10 Noncash liquidation distributions

$ 

11 Exempt-interest dividends

$ 

12 Specified private activity 

bond interest dividends

$ 

13 State 14 State identification no. 15 State tax withheld

$ 

$ 

Form 1099-DIV www.irs.gov/Form1099DIV
Instructions for Payer 

To complete Form 1099-DIV, use:

• The 2021 General Instructions for Certain Information 

Returns, and

• The 2021 Instructions for Form 1099-DIV.

To order these instructions and additional forms, go 

to www.irs.gov/Form1099DIV. 

Caution: Because paper forms are scanned during 

processing, you cannot file Forms 1096, 1097, 1098, 

1099, 3921, or 5498 that you print from the IRS website. 

Due dates. Furnish Copy B of this form to the recipient 

by January 31, 2022. 

File Copy A of this form with the IRS by February 28, 

2022. If you file electronically, the due date is 

March 31, 2022. To file electronically, you must have 

software that generates a file according to the 

specifications in Pub. 1220. The IRS does not provide a 

fill-in form option for Copy A. 

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. See 

the Instructions for Form 1042-S and Pub. 515. 

Need help? If you have questions about reporting on 

Form 1099-DIV, call the information reporting customer 

service site toll free at 866-455-7438 or 304-263-8700 

(not toll free). Persons with a hearing or speech 

disability with access to TTY/TDD equipment can call 

304-579-4827 (not toll free).