‘Type or print
PAYER'S

name, address,

Statement for
Recipients of

1978

Dividends and

zip code, and | Distributions
Federal
identifying Copy C
number. For Payer
Recipient's identifying number T Gross dividends and other dis. | 2 Dividends qualifying for | 3 Dividends not qualtying for | 4 Capital gom distributions
Tributions on stock |? Grelusion exclusion

Type or print RECIPIENT'S name, address, and ZIP code below.

5 Nontaxable distributions
(if determinable)

6 Foreign tax paid (If eligi
ble for foreign tax credit

7 Foreign Country or
U.S. Possession

GPO: 1978-0.263

Form 1099-DIV

520237640

Type or print
PAYER'S
name, address,

Department of the Treasury—Internal Revenue Service

Statement for
Recipients of

1978

Dividends and

Zip code, and | Distributions
Federal
identifying Copy C
number. For Payer
ant’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
(It determinable)

6 Foreign tax paid (If eligi
ble for foreign tax credit)

7 Foreign Country or
U.S. Possession

Ye GPO 1978—0-263.095

Form 1099-DIV

52-0237640

‘Type or print
PAYER'S
name, address,

Department of the Treasury—Internal Revenue Service

Statement for
Recipients of

1978

Dividends and

Zi? cede, and | Distributions
Federal
identifying Copy ©
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 Z!P code below.

5 Nontaxable distributions
(IF determinable)

6 Foreign tax paid (If eligi-
ble for foreign tax credit)

7 Foreign Country or
U.S, Possession

‘te GPO: 1978—0-263.095

Form 1099-DIV

52-0237640

Department of the Treasury—internal Revenue Service




] Statement for
For Official Use Only Recipients of

7 TN ‘int woe
peers "| Dividends and
name, address, | Distributions
ZIP code, and
Federal Copy A
identifying For Internal Revenue
number. Service Center
Recipient's idet 1g number 1 Gross dividends and other dis- [ 2 Dividends qualifying for J 3 Dividends not qualifying for § 4 Capital gain distributions
tributions on stock exclusion exclusion
17
rit rs i 5 Nontaxable distributic 6 Foreign te id (If eligi- | 7 Foreign Countr
Type or print RECIPIENT'S name, address, and ZIP code below (Name must aline ] 5 Nontsable distributions Foreign fax. aid al Foreign Country or
Name b
For instructions on completing this form, see “Instructions
for Form 1096.”"
Form 1099—DIV Ye GPO: 1978—0-263-095 52-0237640 Department of the Treasury—Internal Revenue Serv
Statement for
For Official Use Only Recipients of
i .
pees "| 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 | 3 Dividends not qualifying for § 4 Capital gain distributions
tributions on stock exclusion exclusion
10
i u it 5 Nontaxable distributic 6 Foreign tax paid (If eli 7 Foreign Count
Type or print RECIPIENTS name, addres and ZIP cde bow Name must aline ] § tirgeteiitons 6 Fave ead ay | 7 pcan ©
Name >|
For instructions on completing this form, see “Instructions
for Form 1096.”
Form 1099—DIV ‘$e GPO: 1978—0-263-095 '52-0237640 Department of the Treasury—internal Revenue Service
Statement for
For Official Use Only Recipients of
T int tui
pees") 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 | 4 Capital gain distributions
tributions on stock exclusion exclusion
a9
i m ff 5 Nontaxable distributions 6 Foreign tax paid (If eligi. | 7 Foreign Countr
Type or pant RECIPIENT'S name, address, and ZIP code below (Name must aline Ui determinable) te far foreign tas credit) US Possession
Name >

For instructions on completing this form, see ‘Instructions
for Form 1096.”

Form 1099-—DIV ‘ GPO: 1878—0-263-096 52-0237640 Department of the Treasury—Internal Revenue Service





Statement for
Recipients of
Type or print

PAYER'S Dividends and
name, address,

Zip code, and | Distributions

nt’s identifying number 1 Gross dividends and other dis.

tributions on stock

Type or print RECIPIENT'S name, address, and ZIP code below.

Federal
identifying Copy B
number, For Recipient
qualifying for | 3 Dividends, not qualifying for | 4 Capital gain distributions
exclusion
5 Nontaxable distributions | 6 Foreign tax paid (If eligi- | 7 Foreign Country or
(If determinable) ble for foreign tax credit) U.S, Possession

If 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

x GPO: 1978--0.263-095

§2-0237640 Department of the Treasury—Internal Revenue Service

Statement for
Recipients of

Type or print we

PAYER'S. Dividends and
», address, . A

fir cote, and | Distributions

Federal

identifying Copy B

number. For Recipient

Recipient's identifying number 1 Gross dividends and other dis-

qualifying for | 3 Dividends not qualifying for | 4 Capital gain distributions

tributions on stock

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

If 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

‘Ye GPO: 1978—0-263.05.

52.0237640 Department of the Treasury—Internal Revenue Service

Statement for
Recipients of

Type or print _

PAYER'S Dividends and

name, address, . . .

2iP code, and | Distributions

Federal

identifying Copy B

number. For Recipient

Recipient's identifying number 1 Gross dividends and other dis-

qualifying for | 3 Dividends not qualifying for | 4 Capital gain distributions

tributions on stock

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

If 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
the other recipients and provide each with a copy. However, a husband or wit
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

‘x GPO. 1978.--0.263.095

'52-0237640 Department of the Treasury—Internal Revenue Se