9191 VOID CORRECTED

Gross dividends and other

distributions on stock (Total

of 1b, 1c, 1d, and 1e)

PAYER’S name, street address, city, state, and ZIP code 1a OMB No. 1545-0110

Dividends and

Distributions

$

1b Ordinary dividends

$

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

Internal Revenue

Service Center

RECIPIENT’S name 1d Nontaxable distributions 3 Foreign tax paid

$ $ 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.

Street address (including apt. no.) 1e 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)

$ $

Form 1099-DIV Department of the Treasury - Internal Revenue Service

Do NOT Cut or Separate Forms on This Page

Cat. No. 14415N

Form 1099-DIV

CORRECTED (if checked)

Gross dividends and other

distributions on stock (Total

of 1b, 1c, 1d, and 1e)

PAYER’S name, street address, city, state, and ZIP code 1a OMB No. 1545-0110

Dividends and

Distributions

$

1b Ordinary dividends

$

PAYER’S Federal identification number RECIPIENT’S identification number 1c Capital gain distributions 2 Federal income tax withheld

$ $

RECIPIENT’S name 1d Nontaxable distributions 3 Foreign tax paid

$ $

Street address (including apt. no.) 1e Investment expenses 4 Foreign country or U.S. possession

$

City, state, and ZIP code

Liquidation Distributions

Account number (optional) 5 Cash 6 Noncash (Fair market value)

$ $

Form 1099-DIV Department of the Treasury - Internal Revenue Service

Copy B

For Recipient

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 this

income is taxable and

the IRS determines that

it has not been

reported.

(Keep for your records.)

Form 1099-DIV
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. You can deduct the expenses shown in

box 1e on the “Other expenses” line 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 1e.

Instructions for Recipient

Box 1a.—Gross dividends include any amounts shown in boxes 1b,

1c, 1d, and 1e. If an amount appears in box 1c or 1d or both, you

must file Form 1040. If you file Form 1040A, report the amount in

box 1a. If you file Schedule 1 (Form 1040A) or Schedule B (Form

1040) to report dividends, report the amount in box 1a. If you file

Form 1040 without Schedule B, report the sum of boxes 1b and 1e

on the “Dividend income” line and box 1c on Schedule D (Form

1040) or the “Capital gain or (loss)” line (write “CGD” on the dotted

line).

Box 2.—Shows backup withholding. For example, persons not

furnishing their taxpayer identification number to the payer become

subject to backup withholding at a 31% 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.

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 3.—You may elect to claim the amount shown as a deduction

Box 1b.—Ordinary dividends are fully taxable and are included in or a credit. See Pub. 514, Foreign Tax Credit for Individuals.

box 1a. 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 amounts owned by the other.

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

Box 1d.—This part of the distribution is nontaxable because it is a

return of your cost (or other basis). You must reduce your cost (or

other basis) by this amount for figuring gain or loss when you sell

your stock. But if you get back all your cost (or other basis), you

must report future nontaxable distributions as capital gains, even

though this form shows them as nontaxable. This amount is included

in box 1a. 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
VOID CORRECTED

Gross dividends and other

distributions on stock (Total

of 1b, 1c, 1d, and 1e)

PAYER’S name, street address, city, state, and ZIP code 1a OMB No. 1545-0110

Dividends and

Distributions

$

1b Ordinary dividends

$

PAYER’S Federal identification number RECIPIENT’S identification number 1c Capital gain distributions 2 Federal income tax withheld

$ $

RECIPIENT’S name 1d Nontaxable distributions 3 Foreign tax paid

$ $

Street address (including apt. no.) 1e 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)

$ $

Form 1099-DIV Department of the Treasury - Internal Revenue Service

Copy C

For Payer

For Paperwork

Reduction Act

Notice and

instructions for

completing this

form, see

Instructions for

Forms 1099,

1098, 5498,

and W-2G.

Form 1099-DIV
Payers, Please Note—

Specific information needed to complete this form and other

forms in the 1099 series is given in the 1995 Instructions for

Forms 1099, 1098, 5498, and W-2G. A chart in those

instructions gives a quick guide to which form must be filed

to report a particular payment. You can order those

instructions and additional forms by calling 1-800-TAX-FORM

(1-800-829-3676).

Furnish Copy B of this form to the recipient by January 31,

1996.

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

1996.