‘Statement for
Recipients of
‘Type or print

PAYER'S Dividends and
name, address,

ZIP code, and Distributions

Federal
identifying Copy C
number. For Payer
Reciplent’s identifying number 1 Gross dividends and other dis- for | 3 Dividends not qualifying for | 4 Capital gain dist
tributions on stock exclusion
Type or print RECIPIENT'S name, address, and ZIP code below. 5 Nont ‘butions | 6 Foreign tax paid (If eligi | 7 Foreign Country or
(If determinable) ble for foreign tax credit) U.S. Possession
Form 1099-—DIV ‘tr U.S. GOVERNMENT PRINTING OFFICE: 1976—218-092 El 36-2441915 Department of the Treasury—tinternal Revenue Service
Statement for
Recipients of
Type or print |...
PAYER'S Dividends and
name, address, eg pgs
ZiP code, and | Distributions
Federal
identifying Copy C
number. For Payer
Recipient's identifying number 1 Gross dividends and other dis- | 2 Dividends qualifying for | 3 Dividends not qualifying for | 4 Capital gain distributions
tributions on stock exclusion exclusion
Type or print RECIPIENT'S name, address, and ZIP code below. 5 Nontaxable ributions 6 Foreign tax paid (If eligi- | 7 Foreign Country or
(If determinable) ble for foreign tax credit) U.S. Possession
Form 1099—DIV U.S. GOVERNMENT PRINTING OFFICE: 1976—218-092 E1 36-2441915 Department of the Treasury—internal Revenue Service
Statement for
Recipients of
Type or print} 9. ,
PAYER'S Dividends and
name, address, sgt ge
ZP code, and | Distributions
Federal
identifying Copy C
number. For Payer
Recipient's identifying number 1 Gross dividends and other dis- | 2 Dividends qualifying for | 3 Dividends not qualifying for | 4 Capital gain distributions
tributions on stock exclusion exclusion
" 5 Nontaxable distributi © Foreign tax paid (If eligi- | 7 Foreign Country or
Type or print RECIPIENT'S name, address, and ZIP code below. Nontprable disibutions Foreign fon noid eligh[ 7 Foreign, County

Form 1099-DIV 3 U.S, GOVERNMENT PRINTING OFFICE: 1976—-218-092 £1 36-2441915, Department of the Treasury—tnternal Revenue Ser





For Official Use Only

Statement for
Recipients of

1977

i we
Tyee ce it! Dividends and
name, address, | Distributions
ZIP code, and
Federal Copy A
identifying For Internal Revenue
number. Service Center

= Recipient's Identifying number) 1 Gross dividends and other dis. J 2 Dividends qualifying for ividends not qualifying for | 4 Capital gain distributions

‘tributions on stock exclusion exclusion
19
i i‘ i 5 Nontaxable distributions 6 Foreign tax paid (!f eligi | 7 Foreign Counts
Type opi RECIPIENT'S name, address, and ZIP code below (Name must aline | § Nontaable distribution Koregn fx paid eligi | 7 Fein County or
Name P|
For instructions on completing this form, see “Instructions
for Form 1096."
Form 1099—DIV TUS GOVERNMENT PRINTING OFFICE. 1976--218-092 F1362441919 Department of the Treasury—intemal Revenue Service
I Statement for
Use Only Recipients of
Type or print Oa
Be es Dividends and
name, address, | Distributions
ZIP code, and
Federal Copy A
identifying For Internal Revenue
number, Service Center
jent’s Identifying number J 1 Gross dividends and other dis. J 2 Dividends qualifying for J 3 Dividends not qualifying for [J 4 Capital gain distributions
tributions on stock exclusion exclusion
10
i z @ |] 5 Nontaxable distributions | 6 Foreign tax paid (If eligi- | 7 Foreign Country or
Type oF print RECIPIENT'S name, address, and ZIP code below (Name must aline J 8 Nartazable dite Foreign tax paid (if eg” | 7 Foreign County
Name P|
For instructions on completing this form, see “Instructions
for Form 1096.""
Form 1099—DIV WrUS GOVERNMENT PRINTING OFFICE, 1976—ZTB.OFDEIS67441915 Department of the Treasury—Internal Revenue Service
Statement for
For Official Use Only Recipients of
7 i we
pee ce Pat! Dividends and
name, address, | Distributions
ZIP code, and
Federal Copy A
identifying For Internal Revenue
number. Service Center
- Recipient's identifying number 1 Gross dividends and other dis- 2 Dividends qualifying for [J 3 Dividends not qualifying for [J 4 Capital gain distributions
tributions an stock exclusion exclusion
10)
——
z a ] Nontaxable distributions | 6 Foreign tax paid (If eligi- | 7 Foreign Country or
Type or brn RECIPIENT'S name, address, and ZIP code below (Name must aline J § Nanteable distributions Foraan tax gad eis | 7 forwgn County
Name >|
For instructions on completing this form, see “Instructions
for Form 1096.”

¥ U.S. GOVERNMENT PRINTING OFFICE: 1976 218-092 EI 36.2441915

Form 1099-DIV

Department of the Treasury—internal Revenue Service




Statement for

Recipients of 1977
Type or print woe
PAYER'S Dividends and

name, address,

ziP code, and | Distributions

Federal
identifying Copy B
number. For Recipient
Recipient's identifying number | 1 Gross dividends and other dis- | 2 Dividends qualifying for | 3 Dividends not qualifying for | 4 Capital gain distributions
tributions on stock exclusion ‘exclusion
Type or print RECIPIENT'S name, address, and ZIP code below. 5 Nontaxable distributions 6 Foreign tax paid (If eligi. 7 Foreign Country or
(if deter ible) ble for foreign tax credit) U.S. Possession
form shows two or more recipients, the recipient whose Federal identifying
‘shown should file a Form 1087-DIV with the Internal Revenue Service for
each of the other recipients and provide each with a copy. However, a husband or wife
is not required to file a Form 1087—DIV to show payments for the other.
This information is being furnished to the Internal Revenue
Service.
Form 1099-DIV 4 U.S. GOVERNMENT PRINTING OFFICE: 1976—218-092 £1 36:2441915 Department of the Treasury—Internal Revenue Service
Statement for
Recipients of
Type or print os
PAYER'S Dividends and
name, address, eggs
2iP code, and | Distributions
Federal
identifying Copy B
number. For Recipient
Reciplent’s identifying number 1 Gross dividends and other dis- | 2 Dividends qualifying for not qualifying for | 4 Capital gain distributions
tributions on stoc exclusion
Type or print RECIPIENT'S name, address, and ZIP code below. 5 Nontaxable distributions. 6 Foreign tax paid (If eligi. 7 Foreign Country or
(If determinable) ble for foreign tax credit) U.S. Possession
this form shows two or more recipients, the recipient whose Federal identifying
number is shown should file a Form 1087—DIV with the Internal Revenue Service for
‘each of the other recipients and provide each with a copy. However, a husband or wife
is not required to file a Form 1087-DIV to show payments for the other.
This information is being furnished to the Internal Revenue
Service.
Form 1099-DIV “#USS. GOVERNMENT PRINTING OFFICE, 1976—218-092 €136-2441915 Department of the Treasury—iInternal Revenue Service
Statement for
Recipients of
Type or a
PAYER’S Dividends and
name, address, | ys g ep ge
zIP code, and | Distributions
Federal
identifying Copy B
number, For Recipient
Recipient's identifying number 1 Gross dividends and other dis- | 2 Dividends qualifying for | 3 Dividends not qualifying for | 4 Capital gain distributions
tributions on stock exclusion exclusion

6 Foreign tax paid (If eligi. | 7 Foreign Country or

Type or print RECIPIENT'S name, address, and ZIP code below.
‘ype oF Pr jame, address, and ZIP code below. ble Tor foreign tax eredit) |” U'S. Possession

If this form shows two or more recipients, the recipient whose Federal identifying
‘umber is shown should file a Form 1087-DiV with the Internal Revenue Service for
ach of the other recipients and provide each with a copy. However, a husband or wife
is mot required to file a Form 1087-DIV to show payments for the other.

This information is being furnished to the Internal Revenue
Service.

Form 1099-DIV ‘4 U.S. GOVERNMENT PRINTING OFFICE: 1976—218.092€136-2441915 Department of the Treasury—Internal Revenue Service