(voip

CI CoRRECTED

PAYER’S name, street address, city, state, and ZIP code

OMB No. 1545-0110

1986

1 Gross dividends and other
distributions on stock

Dividends and

PAYER’S Federal identification number

RECIPIENT'S identification number

Distributions
2 Dividends qualifying for exclusion Statement for
Recipients of
3 Dividends not qualifying for | 4 Federal income tax withheld
exclusion Copy C
For Payer

RECIPIENT'S name (first, middle, last)

Street address

City, state, and ZIP code

6 Nontaxable distributions (if

5 Capital gain distributions
determinable)

For Paperwork
Reduction Act
Notice and
instructions for

7 Foreign tax paid B Foreign country or U.S. possession

completing this
form, see

Liquidation Distributions

Instructions for

‘Account number (optional)

9 Cash 110 Noneash (Fair market value)

Forms 1099,
1098, 5498,
1096, and W-2G

Form 1099-DIV

U.S. GOVERNMENT PRINTING OFFICE: 1985-463-161

Ljvoip

Department of the Treasury

{_] CORRECTED

PAYER'S name, street address, city, state, and ZIP code

1 Gross dividends and other | OMB No.1545-0110

distributions on stock

+ Internal Revenue Service

PAYER’S Federal identification number

RECIPIENT'S identification number

1986 Dividends and
Distributions
2 Dividends qualifying for exclusion | Statement for
Recipients of
3 Dividends not qualifying for 4 Federal income tax withheld
exclusion Copy C
For Payer

RECIPIENT'S name (first, middle, last)

Street address

City, state, and ZIP code

6 Nontaxable distributions (if
determinable)

8 Capital gain distributions

For Paperwork
Reduction Act
Notice and

7 Foreign tax pad & Foreign country or U.S. possession

instructions for
completing this
form, see

Liquidation Distributions

Instructions for

Account number (optional)

9 Cash [10 Noncash (Fair market value)

Forms 1099,
1098, 5498,
1096, and W-2G.

Form 1099-DIV

yr U.S. GOVERNMENT PRINTING OFFICE: 1985-463-161

Cvoip

Department of the Treasury

(]corrEcTED

PAYER’S name, street address, city, state, and ZIP code

1 Gross dividends and other | OMB No.1545-0110

distributions on stock

Internal Revenue Service

PAYER'S Federal identification number

RECIPIENT'S identification number

RECIPIENT'S name (first, middle, last)

Street address

City, state, and ZIP code

1986 Dividends and
2 Dividends qualifying forexclusion | Statement for Distributions
Recipients of

3 Dividends not qualifying for 4 Federal income tax withheld
exclusion Copy C
For Payer
5 Capital gain distributions 6 Nontaxable distributions (if For Paperwork
determnable) Reduction Act
Notice and

instructions for

7 Foreign tax paid 8 Foreign country ar U.S. possession

completing this
form, see

Liquidation Distributions

Instructions for

‘Account number (optional)

9 Cash 10 Noncash (Fair market value)

Forms 1099,
1098, 5498,
1096, and W-2G.

Form 1099-DIV

#U.S. GOVERNMENT PRINTING OFFICE: 1985-463-161

Department of the Treasury

Internal Revenue Service


Instructions for Recipient

The dividends listed in Box 2 qualify for the dividend exclusion
You are allowed an exclusion of $100 ($200 in the case of a joint
return) of the total received during the tax year as qualifying
dividends.

Report the amount shown in Box 1 on the Dividends line of your
income tax return or, if required, list your dividends on the
separate schedule of your tax return. Then use the amount in Box
2 to arrive at the proper amount of the exclusion for the year. See
the instructions for your income tax return for more information
on how to report the income and take the exclusion

If the amount shown in Box 1 is a distribution from an employee
stock ownership plan (ESOP), it does not qualify for the dividend
exclusion. Although you should report the ESOP distribution as a
dividend on your income tax return, treat it as a plan distribution,
not as investment income, for any other purpose.

If you receive dividends from a regulated investment company
(including money market funds), the company will tell you if any
portion qualifies for the exclusion.

Any amount shown in Box 4 represents backup withholding. For
example, persons not furnishing their taxpayer identification
number to the payer become subject to backup withholding at a

Instructions for Recipient

The dividends listed in Box 2 qualify for the dividend exclusion.
You are allowed an exclusion of $100 ($200 in the case of a joint
return) of the total received during the tax year as qualifying
dividends.

Report the amount shown in Box 1 on the Dividends line of your
income tax return or, if required, list your dividends on the
separate schedule of your tax return. Then use the amount in Box
2 to arrive at the proper amount of the exclusion for the year. See
the instructions for your income tax return for more information
on how to report the income and take the exclusion.

If the amount shown in Box 1 is a distribution from an employee
stock ownership plan (ESOP), it does not qualify for the dividend
exclusion. Although you should report the ESOP distribution as a
dividend on your income tax return, treat it as a plan distribution,
not as investment income, for any other purpose.

If you receive dividends from a regulated investment company
(including money market funds), the company will tell you if any
portion qualifies for the exclusion.

Any amount shown in Box 4 represents backup withholding. For
example, persons not furnishing their taxpayer identification
number to the payer become subject to backup withholding at a

Instructions for Recipient

The dividends listed in Box 2 qualify for the dividend exclusion.
You are allowed an exclusion of $100 ($200 in the case of a joint
return) of the total received during the tax year as qualifying
dividends

Report the amount shown in Box 1 on the Dividends line of your
income tax return or, if required, list your dividends on the
separate schedule of your tax return. Then use the amount in Box
2 to arrive at the proper amount of the exclusion for the year. See
the instructions for your income tax return for more information
on how to report the income and take the exclusion.

If the amount shown in Box 1 is a distribution from an employee
stock ownership plan (ESOP), it does not qualify for the dividend
exclusion. Although you should report the ESOP distribution as a
dividend on your income tax return, treat it as a plan distribution,
not as investment income, for any other purpose.

If you receive dividends from a regulated investment company
(including money market funds), the company will tell you if any
portion qualifies for the exclusion.

Any amount shown in Box 4 represents backup withholding. For
example, persons not furnishing their taxpayer identification
number to the payer become subject to backup withholding at a

20% rate on certain payments. See Form W-9, Payer’s Request
for Taxpayer Identification Number and Certification, for
information on backup withholding. Include this amount on your
income tax return as tax withheld.

Amounts listed in Box 6 as nontaxable distributions are usually a
return of capital. Once you have received an amount equal to your
cost, or other basis, these distributions are taxable to you as a
capital gain even if the payer lists them as nontaxable. For more
information, see Publication 550, Investment Income and
Expenses

If your Federal identification number is shown on this form, and
two or more recipients are shown or the form includes amounts
belonging to another person, you are considered a nominee
recipient. You must file Form 1099-DIV for each of the other
owners showing the income allocable to each. File Form(s) 1099-
DIV with Form 1096, Annual Summary and Transmittal of U.S.
Information Returns, at the Internal Revenue Service Center for
your area. On Forms 1099-DIV and 1096, you should be listed as
the “payer.” On Form 1099-DIV, the other owner(s) should be
listed as the “recipient.” A husband or wife is not required to file a
nominee return to show payments for the other.

20% rate on certain payments. See Form W-9, Payer’s Request
for Taxpayer Identification Number and Certification, for
information on backup withholding. Include this amount on your
income tax return as tax withheld.

Amounts listed in Box 6 as nontaxable distributions are usually a
return of capital. Once you have received an amount equal to your
cost, or other basis, these distributions are taxable to you asa
capital gain even if the payer lists them as nontaxable. For more
information, see Publication 550, Investment Income and
Expenses.

4f your Federal identification number is shown on this form, and
two or more recipients are shown or the form includes amounts
belonging to another person, you are considered a nominee
recipient. You must file Form 1099-DIV for each of the other
owners showing the income allocable to each. File Form(s) 1099-
DIV with Form 1096, Annual Summary and Transmittal of U.S.
Information Returns, at the Internal Revenue Service Center for
your area. On Forms 1099-DIV and 1096, you should be listed as
the “payer.” On Form 1099-DIV, the other owner(s) should be
listed as the “recipient.” A husband or wife is not required to file a
nominee return to show payments for the other

20% rate on certain payments. See Form W-9, Payer’s Request
for Taxpayer Identification Number and Certification, for
information on backup withholding. Include this amount on your
income tax return as tax withheld.

Amounts listed in Box 6 as nontaxable distributions are usually a
return of capital. Once you have received an amount equal to your
cost, or other basis, these distributions are taxable to you as a
capital gain even if the payer lists them as nontaxable. For more
information, see Publication 550, Investment Income and
Expenses.

lf your Federal identification number is shown on this form, and
two or more recipients are shown or the form includes amounts
belonging to another person, you are considered a nominee
recipient. You must file Form 1099-DIV for each of the other
owners showing the income allocable to each. File Form(s) 1099-
DIV with Form 1096, Annual Summary and Transmittal of U.S.
Information Returns, at the Internal Revenue Service Center for
your area. On Forms 1099-DIV and 1096, you should be listed as
the “payer.” On Form 1099-DIV, the other owner(s) should be
listed as the “recipient.” A husband or wife is not required to file a
nominee return to show payments for the other


VOID [XK] CORRECTED _ For Official Use Only

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Form 1099-DIV Do NOT Cut or Separate Forms on This Page Department of the Treasury - Internal Revenue Service

CORRECTED For Official Use Only

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Form 1099-DIV Do NOT Cut or Separate Forms on This Page Department of the Treasury - Internal Revenue Service

CORRECTED _ For Official Use Only
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Dividends and

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‘Notice and
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completing this

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City, state, and ZIP code Liquidation Distributions Instructions for
Forms.1099,
1098, 5498,

a 1096, and W-26.

Department of the Treasury - Internal Revenue Service

‘Account number (optional)

Form 1099-DIV Do NOT Cut or Separate Forms on This Page




{| CORRECTED

PAYER’S name, street address, city, state, and ZIP code

PAYER'S Federal identification number | RECIPIENT'S identification number

1 Gross dividends and other OMB No.1545-0110
distributions on stock
1986 Dividends and
F Dundends quaniyngloreicus Distributions
wadends qualiyng forexciuson | Statement for
Recipients of
3 Dividends not qualifying for | 4 Federal income tax withheld Copy B

exclusion

For Recipient
This 1s important tax

RECIPIENT'S name (first, middle, last)

Street address

City, state, and ZIP code

5 Capital gain distributions

information and is
being furnished to
the internal Revenue
Service. If you are
required toile a

6 Nontaxable distributions (if
ceterminable)

7 Foreign tax paid

return, a negligence
penalty or other
sanction will be

& Foreign country oF U.S. possession

Liquidation Distributions

imposed on you if
this dividend income

9 Cash 110 Noncash (Fair market value) 's taxable and the
‘Account number (optional) IRS determines that
reported.
Form 1099-DIV Department of the Treasury - Internal Revenue Service
[[) CORRECTED
PAYER'S name, street address, city, state, and ZIP code 1 Gross dividends and other] OMB No.1545-0110
distributions on stock
1986 Dividends and
Distributions
2 Didends qualifying torexcusion | Statement for
Recipients of
3 Dividends not qualifying for | 4 Federal income tax withheld Copy B

PAYER’S Federal identification number | RECIPIENT'S identification number

exclusion

For Recipient

This is important tax
information and is

RECIPIENT'S name (first, middle, last)

Street address,

City, state, and ZIP code

5 Capital gain distributions

6 Nontaxable distributions (if

being furnished to
determinable)

the Internal Revenue
Service. If you are
required to file a

7 Foreign tax paid

return, a negligence
penalty or other
sanction will be

8 Foreign country or U.S. possession

Liquidation Distributions

imposed on you if
this dividend income

9 Cash [10 Noncash (Fair market value) is taxable and the

IRS determines that

Account number (optional) it has not been

reported.

Form 1099-DIV Department of the Treasury - Internat Revenue Service
{_] CORRECTED

PAYER'S name, street address, city, state, and ZIP code

1 Gross dividends and other
distributions on stock

OMB No. 1545-0110

1986

Dividends and

PAYER’S Federal identification number | RECIPIENT'S identification number

Distributions
2 Dividends qualifying forexclusion | Statement for
Recipients of

3 Dividends not qualifying for] 4 Federal income tax withheld Copy B

exclusion

For Recipient
This is important tax

RECIPIENT'S name (first, middle, last)

Street address

City, state, and ZIP code

5 Capital gain distributions

information and 1s
being furnished to
the Internal Revenue
Service. If you are
required to file a

6 Nontaxable distributions (if
determinable)

7 Foreign tax paid

return, a negligence
penalty or other
sanction will be

8 Foreign country or U.S. possession

Liquidation Distributions

imposed on you if
this dividend income

‘Account number (optional)

9 Cash

110 Noncash (Fair market value) is taxable and the
IRS determines that

it has not been

reported.

Form 1099-DIV

Department of the Treasury - Internal Revenue Service