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PAYER'S name, street address, city, state, and ZIP code 1a Gross dividends and other | OMB No. 1545-0110
distributions on stock (Total
of 1b, 1c, 1d, and le) Dividends and
5 __ 1991 Distributions
1b Ordinary diudends
$
PAYER’S Federal identification number | RECIPIENT'S ide le Capital gain distributions 2 Federal income tax withheld Copy c
$ $ For Payer
RECIPIENT'S name 1d Nontaxable distributions ‘3 Foreign tax paid For Paperwork
Reduction Act
$ $ Notice and
instructions for
Street address (including apt. no.) Te Investment expenses “4 Foreign country or U.S. possession] completing this
$ form, see
ci Instructions for
iy stat, and ZIP code Liquidation Distributions coe eee,
‘Account number (optional) 2nd TINNot.| 5 Cash © _Noncash (Fair market value) and W-2G.
$ $
Form 1099-DIV Department of the Treasury - Internal Revenue Service
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PAYER'S name, street address, city, state, and ZIP code la Gross dividends and other | OMB No. 1545-0110
distributions on stock (Total
of 1b, 1c, 1d, and le) Dividends and
$_ 1991 Distributions
1b Ordinary dividends
$
PAYER'S Federal identification number | RECIPIENT'S identification number 1c Capital gain distributions 2 Federal income tax withheld Copy Cc
For Payer
RECIPIENT'S name 1d Nontaxable distributions 3 Forelgn tax pald For Paperwork
Reduction Act
$ $ ____ Notice and
instructions for
Street address (including apt. no.) Je Investment expenses “4 Forergn country or U.S. possession] completing this
rm, See
City,state, and ZIP code s Instructions for
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$ $
Form 1099-DIV Department of the Treasury - Internal Revenue Service
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PAYER'S name, street address, city, state, and ZIP code 1a Gross dividends and other | OMB No. 1545-0110
distributions on stock (Tota!
of 1b, 1c, 1d, and le) Dividends and
§ 1991 Distributions
1b Ordinary dividends

$

PAYER'S Federal identification number] RECIPIENT'S identification number | 1¢ Capital gaindistributions | 2 Federal come tax withheld Copy C
$ $ For Payer
RECIPIENTS name 14 Nontaxable distributions 3 Foreign tax pard For Paperwork
Reduction Act
$ $ Notice and
instructions for
Street address (including apt. no.) Te Investment expenses  Foragn country or US. posseson! completing this
$ form, see
ct 2 Instructions for
i, state, and ZIP code Liquidation Distributions Form 1003"
‘Account number (optional) 2nd TIN Not.| 5 Gash & _Noncash (Fair market value) and W-26.

$ $

Form 1099-DIV

Department of the Treasury - Internal Revenue Service


Instructions for Recipient

Box 1a.—Gross dividends include any amounts shown in Boxes 1b,
Ic, 1d, and le. If you file Form 1040A, report the sum of Boxes 1b
and le. If you file Schedule B (Form 1040), to report dividends,
report Box 1a on Schedule B. If you file Form 1040 without Schedule
B, report the sum of Boxes 1b and le on the “Dividend income" line
and Box 1c on Schedule D (Form 1040) or the “Capital gain
distributions” line.

The amount shown may be a distribution from an employee stock
ownership plan (ESOP). 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.

Box 1b.—Ordinary dividends are fully taxable and are included

in Box la.

Box 1c.—Capital gain distributions are included in Box 1a.

Box 1d.—These distributions are not currently taxable because they
are usually a return of capital that reduce your basis in the stock. If you
dispose of the stock, your basis for figuring your gain or loss is reduced
by the amount in Box 1d. If your basis has been reduced to zero, then
you must report nontaxable distributions as a capital gain even though
the payer lists them as nontaxable. This amount is included in Box 1a.
For more information, see Pub. 550, Investment Income and
Expenses.

Box le.—Any amount shown is your share of the expenses of a
nonpublicly offered regulated investment company, generally a

Instructions for Recipient

Box 1a.—Gross dividends inciude any amounts shown in Boxes 1b,
1c, 1d, and le. I you file Form 1040A, report the sum of Boxes 1b
and le. If you file Schedule B (Form 1040), to report dividends,
report Box 1a on Schedule B. If you file Form 1040 without Schedule
B, report the sum of Boxes 1b and le on the “Dividend income” line
and Box 1c on Schedule D (Form 1040) or the “Capital gain
distributions” line.

The amount shown may be a distribution from an employee stock
ownership plan (ESOP). 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
Box 1b.—Ordinary dividends are fully taxable and are included
in Box la.

Box 1¢.—Capital gain distributions are included in Box 1a.

Box 1d.—These distributions are not currently taxable because they
are usually a return of capital that reduce your basis in the stock. If you
dispose of the stock, your basis for figuring your gain or loss is reduced
by the amount in Box 1d. If your basis has been reduced to zero, then
you must report nontaxable distributions as a capital gain even though
the payer lists them as nontaxable. This amount is included in Box la.
For more information, see Pub. 550, Investment Income and
Expenses.

Box 1e.-—Any amount shown is your share of the expenses of a
nonpublicly offered regulated investment company, generally a

Instructions for Recipient

Box 1a.—Gross dividends include any amounts shown in Boxes 1b,
1c, 1d, and 1e. If you file Form 1040A, report the sum of Boxes 1b
and le. If you file Schedule B (Form 1040), to report dividends,
report Box 1a on Schedule B. If you file Form 1040 without Schedule
B, report the sum of Boxes 1b and le on the “Dividend income” line
and Box 1c on Schedule D (Form 1040) or the “Capital gain
distributions” line.

The amount shown may be a distribution from an empioyee stock
ownership plan (ESOP). 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.

Box 1b.—Ordinary dividends are fully taxable and are included

in Box la.

Box 1¢.—Capital gain distributions are included in Box la.

Box 1d.—These distributions are not currently taxable because they
are usually a return of capital that reduce your basis in the stock. If you
dispose of the stock, your basis for figuring your gain or loss is reduced
by the amount in Box 1d. If your basis has been reduced to zero, then
you must report nontaxable distributions as a capital gain even though
the payer lists them as nontaxable. This amount is included in Box la.
For more information, see Pub. 550, Investment Income and
Expenses.

Box 1e.—Any amount shown is your share of the expenses of a
nonpublicly offered regulated investment company, generally a

nonpublicly offered mutual fund, which is included as a dividend in
Box 1a. The full amount shown in Box 1a must be reported as income
on your tax return. The expenses shown in Box le are deductible as a
“Miscellaneous Deduction” on Schedule A (Form 1040) subject to the
2% limit. Generally, the actual amount you should have received or
had credited to you is the amount in Box 1a less the amount in Box le.
Box 2.—Shows 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, Request for Taxpayer Identification Number and
Certification, for information on backup withholding. Include this
amount on your income tax return as tax withheld.

Box 3.—You may elect to claim the amount shown as a deduction or a
credit. See Pub. 514, Foreign Tax Credit for Individuals.
Nominees.—If your Federal identification number is shown on this
form and 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, and
you must furnish a Form 1099-DIV 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 each Form 1099-DIV, list yourself as the “payer” and the
other owner as the “recipient.” On Form 1096, list yourself as the
“filer.” A husband or wife is not required to file a nominee return to
show payments owned by the other.

nonpublicly offered mutual fund, which is included as a dividend in
Box la. The full amount shown in Box 1a must be reported as income
‘on your tax return. The expenses shown in Box le are deductible as a
“Miscellaneous Deduction” on Schedule A (Form 1040) subject to the
2% limit. Generally, the actual amount you should have received or
had credited to you is the amount in Box 1a less the amount in Box le.
Box 2.—Shows 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, Request for Taxpayer Identification Number and
Certification, for information on backup withholding. Include this
amount on your income tax return as tax withheld.

Box 3.—You may elect to ciaim the amount shown as a deduction or a
credit. See Pub. 514, Foreign Tax Credit for Individuals.
Nominees.—If your Federal identification number is shown on this
form and 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, and
you must furnish a Form 1099-DIV 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 each Form 1099-DIV, list yourself as the “payer” and the
other owner as the “recipient.” On Form 1096, list yourself as the
“filer.” A husband or wife is not required to file a nominee return to
show payments owned by the other.

nonpublicly offered mutual fund, which is included as a dividend in
Box 1a. The full amount shown in Box 1a must be reported as income
on your tax return. The expenses shown in Box le are deductible as a
“Miscellaneous Deduction” on Schedule A (Form 1040) subject to the
29% limit. Generally, the actual amount you should have received or
had credited to you is the amount in Box 1a less the amount in Box le.
Box 2.—Shows 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, Request for Taxpayer Identification Number and
Certification, for information on backup withholding, Include this
amount on your income tax return as tax withheld.

Box 3.—You may elect to claim the amount shown as a deduction or a
credit. See Pub. 514, Foreign Tax Credit for Individuals.
Nominees.—If your Federal identification number is shown on this
form and 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, and
you must furnish a Form 1099-DIV 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 each Form 1099-DIV, list yourself as the “payer” and the
other owner as the “recipient.” On Form 1096, list yourself as the
“filer.” A husband or wife is not required to file a nominee return to
show payments owned by the other.


44a C vow

CJ correcTeD

‘Type or machine print PAYER’S name, street address, city, state; and ZIP code

Ja Gross dividends and other
distributions on stock (Total
of 1b, 1¢, 1d, and 1e)

$

1b Ordinary dividends

$

OMB No. 1545-0110

1991

Dividends and
Distributions

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

1c Capital gain distributions

2. Federal income tax withheld

wn

‘Type or machine print RECIPIENT'S name

1d Nontaxable distributions

$

3 Foreign tax paid

Street address (including apt. no.)

le Investment expenses

$

‘4 Foreign country or U.S. possession

City, state, and ZIP code

Liquidation Distributions

‘Account number (optional) 2nd TIN Not.

5 Cash

6 Noncash (Fair market value)

Copy A
For
Internal Revenue
Service Center
File with Form 1096.
For Paperwork
Reduction Act Notice
and instructions for
completing this
form, see
Instructions for
Forms 1099, 208
auo8,

and W-2G.

Form 1099-DIV

4151 Ovo

Do NOT Cut or Separate Forms on This Page

CI correcTeD

Type or machine print PAYER’S name, street address, city, state, and ZIP code

a Gross dividends and other
distributions on stock (Total
of 1b, 1c, 1d, and 1e)

$

1b Ordinary dividends

$

OMB No. 1545-0110

1991

Department of the Treasury - Internal Revenue Service

Dividends and
Distributions

PAYER’S Federal identification number | RECIPIENT'S identification number | 1¢ Capital gain distributions | 2 Federal income tax withheld Copy A
$ For

‘Type or machine print RECIPIENT'S name ‘1d_ Nontaxable distributions 3 Foreign tax paid Internal Revenue
Service Center

$ $ File with Form 1096.

7 7 ; For Paperwork

‘Street address (including apt. no.) le Investment expenses 4 Foreign country or U.S. possession Reduction Act Notice
$ and instructions fr

completing this

ity, state, and ZIP code Liquidation Distributions form, see
Instructions for

‘Account number (optional) 2nd TIN Not. | Cash @ Noncash (Fair market vaiue)| Forms 1099, 2098
$ $ and W-26.

Form 1099-DIV

4191 Ovo

Do NOT Cut or Separate Forms on This Page

CI correcTep

Type or machine print PAYER’S name, street address, city, state, and ZIP code

Ja Gross dividends and other
of 1b, 1c, 1d, and le)

$

distributions on stock (Total

OMB No. 1545-0110

‘1b Ordinary dividends

$

1991

Department of the Treasury - Internal Revenue Service

Dividends and
Distributions

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

1c Capital gain distributions

$

2 Federal income tax withheld

$

‘Type or machine print RECIPIENT'S name

1d Nontaxable distributions

$

‘3. Foreign tax paid

$

Street address (including apt. no.)

le Investment expenses

$

‘4 Foreign country or U.S. possession

City, state, and ZIP code

Liquidation Distributions

‘Account number (optional) ‘2nd TIN Not.

5 Cash

6 Noncash (Fair market value)

$

CopyA

For

Internal Revenue
Service Center
File with Form 1096.
For Paperwork
Reduction Act Notice
and instructions for
completing this
form, see
Instructions for
Forms 1099, 1098,

5498,
and W-2G.

Form 1099-DIV

Department of the Treasury - Internal Revenue Service




(J coRRECTED (if checked)

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

a Gross dividends and other
distributions on stock (Total
of 1b, 1c, 1d, and 1e)

$

1b Ordinary dividends

$

‘OMB No. 1545-0110

1991

Dividends and
Distributions

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

1 Capital gain distributions

2. Federal income tax withheld} Copy B
$ For Recipient

RECIPIENT'S name

Street address (including apt. no.)

City, state, and ZIP code

1d Nontaxable distributions

$

3 Foreign tax pad This is important tax

information and is
being furnished to the
$ internal Revenue

Je Investment expenses

$

Service. If you are
required to file a return,
‘a negligence penalty or

4 Foreign country or U.S. possession

Liquidation Distributions

other sanction may be
imposed on you if this
dividend income is
taxable and the IRS

Account number (optional)

5 Cash

determines that it has,

6 Noncash (Fair market value) oot been reported

$

Form 1099-DIV

Department of the Treasury - Internal Revenue Service

(] CORRECTED (if checked)

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

1a Gross dividends and other
distributions on stock (Total
of 1b, 1c, 14, and 1e)

$

1b Ordinary dividends

$

OMB No. 1545-0110

1991

Dividends and
Distributions

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

1c Capital gain distributions

2 Federal income tax withheld Copy B
$ For Recipient

RECIPIENT'S name

Street address (including apt. no.)

City, state, and ZIP code

1d_ Nontaxable distributions

$

3. Foreign tax paid This is important tax
information andis
being furnished to the

$ internal Revenue

1e Investment expenses

$

Service. If you are
required to file a return,
a negligence penalty or

‘4 Foreign country or US. possession

Liquidation Distributions

other sanction may be
imposed on you if this
‘dividend income is
taxable and the IRS

‘Account number (optional)

5 Cash

determines that it has

 Noncash (Fair market value) rcs tat tes

$

Form 1099-DIV

Department of the Treasury - Internal Revenue Service

CJ CORRECTED (if checked)

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

Ja Gross dividends and other
distributions on stock (Total
of 1b, 1c, 1d, and Le)

$

OMB No. 1545-0110
Dividends and

1b Ordinary dividends

$

Distributions

1991

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

1c Capital gain distributions

$

2 Federal income tax withheld Copy B
$ For Recipient

RECIPIENT'S name

Street address (including apt. no.)

City, state, and ZIP code

1d Nontaxabie distributions

$

3 Foreign tax pad This is important tax

information and is
being furnished to the
$ Internal Revenue

Je Investment expenses

$

Service. If you are
required to flea return,
a negligence penalty or

4 Foreign country or U.S. possession

Liquidation Distributions

other sanction may be
imposed on you if this
dividend income is
taxable and the IRS

‘Account number (optional)

5 Cash

determines that it has,

6 Noncash (Fair market value) not been reported

Form 1099-DIV

Department of the Treasury - Internal Revenue Service