7373 VOID CORRECTED

CORPORATION’S name, street address, city, state, ZIP code, and telephone no. OMB No. 1545-1814

2

1

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

SHAREHOLDER’S name

Street address (including apt. no.)

City, state, and ZIP code

Form 1099-CAP Cat. No. 35115M Department of the Treasury - Internal Revenue Service

Form 1099-CAP

Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page

Copy A

For

Internal Revenue

Service Center

File with Form 1096.

For Paperwork

Reduction Act

Notice, see the

2011 General

Instructions for

Certain Information

Returns.

Changes in

Corporate

Control and

Capital Structure

5

Date of sale or exchange

Aggregate amount rec’d*

Account number (see instructions)

3 No. of shares exchanged

* The shareholder cannot claim a loss based on the

amount in box 2.

$

4 Classes of stock exchanged

2011
CORRECTED (if checked)

Copy B

For Shareholder

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.

Form 1099-CAP (keep for your records) Department of the Treasury - Internal Revenue Service

Changes in

Corporate

Control and

Capital Structure

CORPORATION’S name, street address, city, state, ZIP code, and telephone no. OMB No. 1545-1814

2

1

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

SHAREHOLDER’S name

Street address (including apt. no.)

City, state, and ZIP code

Form 1099-CAP

5

Date of sale or exchange

Aggregate amount rec’d*

Account number (see instructions)

3 No. of shares exchanged

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

$

4 Classes of stock exchanged

2011
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.

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

stock that you held which were exchanged in the

transaction.

Box 1. Shows the date the stock was exchanged for

cash, stock, or other property.

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

exchanged.

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.

Account number. May show an account or other unique

number the payer corporation assigned to distinguish

your account.
VOID CORRECTED

For Corporation

For Paperwork

Reduction Act

Notice, see the

2011 General

Instructions for

Certain Information

Returns.

Copy C

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

Changes in

Corporate

Control and

Capital Structure

CORPORATION’S name, street address, city, state, ZIP code, and telephone no. OMB No. 1545-1814

2

1

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

SHAREHOLDER’S name

Street address (including apt. no.)

City, state, and ZIP code

Form 1099-CAP

5

Date of sale or exchange

Aggregate amount rec’d*

Account number (see instructions)

3 No. of shares exchanged

* The shareholder cannot claim a loss based on the

amount in box 2.

$

4 Classes of stock exchanged

2011
Instructions for Corporation

General and specific form instructions are provided as

separate products. The products you should use are

the 2011 General Instructions for Certain Information

Returns and the 2011 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).

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

the shareholder by January 31, 2012. However, if the

recipient is a clearing organization, furnish Copy B by

January 5, 2012.

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

2012. If you file electronically, the due date is April 2,

2012. 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.

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.

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.