Form 1099-CAP

2012

Cat. No. 35115M

Changes in 

Corporate 

Control and 

Capital Structure

Copy A

For 

Internal Revenue 

Service Center

Department of the Treasury - Internal Revenue Service

File with Form 1096. 

OMB No. 1545-1814

For Paperwork 

Reduction Act 

Notice, see the 

2012 General 

Instructions for 

Certain Information 

Returns.

7373 VOID CORRECTED

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

CORPORATION’S federal identification no. SHAREHOLDER’S identification no.

SHAREHOLDER’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (see instructions)

1 Date of sale or exchange

2 Aggregate amount rec'd*

$

3 No. of shares exchanged 4 Classes of stock exchanged

5

* The shareholder cannot claim a loss based on the 

amount in box 2.

Form 1099-CAP

Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page
Form 1099-CAP

2012

Changes in 

Corporate 

Control and 

Capital Structure

Copy B

For Shareholder

Department of the Treasury - Internal Revenue Service

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 

taxable income results 

from this transaction 

and the IRS determines 

that it has not been 

reported.

OMB No. 1545-1814

CORRECTED (if checked)

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

CORPORATION’S federal identification no. SHAREHOLDER’S identification no.

SHAREHOLDER’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (see instructions)

1 Date of sale or exchange

2 Aggregate amount rec'd*

$

3 No. of shares exchanged 4 Classes of stock exchanged

5

* You cannot claim a loss based on the amount in box 2.

Form 1099-CAP (keep for your records)
Instructions for Shareholder

A corporation in which you own stock that has had a 

change in control or a substantial change in capital 

structure must send you this statement by January 31 of 

the year following the calendar year of the change. You 

have received this statement because the corporation 

has reasonably determined that you may be required to 

recognize gain from the receipt of cash, stock, or other 

property that was exchanged for the corporation’s 

stock. Report any gain from the exchange on Schedule 

D (Form 1040), Capital Gains and Losses. However, you 

cannot claim a (loss) on Schedule D (Form 1040) as a 

result of this exchange. See Pub. 550, Investment 

Income and Expenses, chapter 4, for additional 

information.

Shareholder's identification number. For your 

protection, this form may show only the last four digits 

of your social security number (SSN), individual 

taxpayer identification number (ITIN), or adoption 

taxpayer identification number (ATIN). However, the 

issuer has reported your complete identification number 

to the IRS and, where applicable, to state and/or local 

governments.

Account number. May show an account or other 

unique number the payer corporation assigned to 

distinguish your account.

Box 1. Shows the date the stock was exchanged for 

cash, stock, or other property.

Box 2. Shows the aggregate amount of any cash and 

the fair market value of any stock or other property 

received by you in the exchange for the stock you held.

Box 3. Shows the number of shares of the corporation’s 

stock that you held which were exchanged in the 

transaction.

Box 4. Shows the class or classes of stock that were 

exchanged.
Form 1099-CAP

2012

Changes in 

Corporate 

Control and 

Capital Structure

Copy C

For Corporation

Department of the Treasury - Internal Revenue Service

OMB No. 1545-1814

For Paperwork 

Reduction Act 

Notice, see the 

2012 General 

Instructions for 

Certain Information 

Returns.

VOID CORRECTED

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

CORPORATION’S federal identification no. SHAREHOLDER’S identification no.

SHAREHOLDER’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (see instructions)

1 Date of sale or exchange

2 Aggregate amount rec'd*

$

3 No. of shares exchanged 4 Classes of stock exchanged

5

* The shareholder cannot claim a loss based on the 

amount in box 2.

Form 1099-CAP
Instructions for Corporation

General and specific form instructions are provided as 

separate products. The products you should use are the 

2012 General Instructions for Certain Information 

Returns and the 2012 Instructions for Form 1099-CAP. 

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, visit 

IRS.gov or call 1-800-TAX-FORM (1-800-829-3676).

Caution: Because paper forms are scanned during 

processing, you cannot file with the IRS Forms 1096, 

1097, 1098, 1099, 3921, 3922, or 5498 that you print 

from the IRS website.

Due dates. Generally, furnish Copy B of this form to the 

shareholder by January 31, 2013. However, if the 

recipient is a clearing organization, furnish Copy B by 

January 7, 2013.

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

2013. If you file electronically, the due date is April 1, 

2013. To file electronically, you must have software that 

generates a file according to the specifications in Pub. 

1220, Specifications for Filing Forms 1097, 1098, 1099, 

3921, 3922, 5498, 8935, and W-2G Electronically. IRS 

does not provide a fill-in form option.

Need help? If you have questions about reporting on 

Form 1099-CAP, call the information reporting customer 

service site toll free at 1-866-455-7438 or 304-263-8700 

(not toll free). For TTY/TDD equipment, call 

304-579-4827 (not toll free). The hours of operation are 

Monday through Friday from 8:30 a.m. to 4:30 p.m., 

Eastern time.