9191 VOID CORRECTED

OMB No. 1545-0110 

2011

Form 1099-DIV 

Dividends and 

Distributions 

Copy A 

For 

Internal Revenue 

Service Center 

File with Form 1096.

For Privacy Act 

and Paperwork 

Reduction Act 

Notice, see the 

2011 General 

Instructions for 

Certain 

Information 

Returns. 

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

PAYER’S federal identification 

number 

RECIPIENT’S identification 

number 

RECIPIENT’S name 

Street address (including apt. no.) 

City, state, and ZIP code 

Account number (see instructions) 2nd TIN not. 

1a Total ordinary dividends 

$ 

1b Qualified dividends

$ 

2a Total capital gain distr.

$ 

2b Unrecap. Sec. 1250 gain 

$ 

2c Section 1202 gain 

$ 

2d Collectibles (28%) gain 

$ 

3 Nondividend distributions 

$ 

4 Federal income tax withheld 

$ 

5 Investment expenses 

$ 

6 Foreign tax paid 

$ 

7 Foreign country or U.S. possession 

8 Cash liquidation distributions 

$ 

9 Noncash liquidation distributions 

$ 

Form 1099-DIV Cat. No. 14415N Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page
CORRECTED (if checked)

OMB No. 1545-0110 

2011

Form 1099-DIV 

Dividends and 

Distributions 

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. 

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

PAYER’S federal identification 

number 

RECIPIENT’S identification 

number 

RECIPIENT’S name 

Street address (including apt. no.) 

City, state, and ZIP code 

Account number (see instructions) 

1a Total ordinary dividends 

$ 

1b Qualified dividends

$ 

2a Total capital gain distr.

$ 

2b Unrecap. Sec. 1250 gain 

$ 

2c Section 1202 gain 

$ 

2d Collectibles (28%) gain 

$ 

3 Nondividend distributions 

$ 

4 Federal income tax withheld 

$ 

5 Investment expenses 

$ 

6 Foreign tax paid 

$ 

7 Foreign country or U.S. possession 

8 Cash liquidation distributions 

$ 

9 Noncash liquidation distributions 

$ 

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

Account number. May show an account or other unique number the payer 

assigned to distinguish your account. 

Box 1a. Shows total ordinary dividends that are taxable. Include this amount on 

line 9a of Form 1040 or 1040A. Also, report it on Schedule B (Form 1040 or 

1040A), if required. 

The amount shown may be dividends a corporation paid directly to you as a 

participant (or beneficiary of a participant) in an employee stock ownership plan 

(ESOP). Report it as a dividend on your Form 1040/1040A but treat it as a plan 

distribution, not as investment income, for any other purpose. 

Box 1b. Shows the portion of the amount in box 1a that may be eligible for the 

15% or zero capital gains rates. See Form 1040/1040A instructions for how to 

determine this amount. Report the eligible amount on line 9b, Form 1040 or 

1040A.

Box 2a. Shows total capital gain distributions from a regulated investment 

company or real estate investment trust. Report the amounts shown in box 2a 

on Schedule D (Form 1040), line 13. But, if no amount is shown in boxes 2c–2d 

and your only capital gains and losses are capital gain distributions, you may be 

able to report the amounts shown in box 2a on line 13 of Form 1040 (line 10 of 

Form 1040A) rather than Schedule D. See the Form 1040/1040A instructions. 

Box 2b. Shows the portion of the amount in box 2a that is unrecaptured section 

1250 gain from certain depreciable real property. Report this amount on the 

Unrecaptured Section 1250 Gain Worksheet–Line 19 in the Schedule D 

instructions (Form 1040). 

Box 2c. Shows the portion of the amount in box 2a that is section 1202 gain

from certain small business stock that may be subject to a 50% exclusion and 

certain empowerment zone business stock that may be subject to a 60% 

exclusion. See the Schedule D (Form 1040) instructions. 

Box 2d. Shows 28% rate gain from sales or exchanges of collectibles. If 

required, use this amount when completing the 28% Rate Gain Worksheet–Line 

18 in the instructions for Schedule D (Form 1040). 

Box 3. Shows the part of the distribution that 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), report future distributions as capital gains. See Pub. 

550, Investment Income and Expenses. 

Box 4. Shows backup withholding. A payer must backup withhold on certain 

payments if you did not give your taxpayer identification number to the payer. 

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 5. Shows your share of expenses of a nonpublicly offered regulated 

investment company, generally a nonpublicly offered mutual fund. If you file 

Form 1040, you may deduct these expenses on the “Other expenses” line on 

Schedule A (Form 1040) subject to the 2% limit. This amount is included in 

box 1a. 

Box 6. Shows the foreign tax that you may be able to claim as a deduction or a 

credit on Form 1040. See the Form 1040 instructions. 

Box 7. This box should be left blank if a regulated investment company reported 

the foreign tax shown in box 6. 

Boxes 8 and 9. Shows cash and noncash liquidation distributions. 

Nominees. If this form includes amounts belonging to another person, you are 

considered a nominee recipient. You must file Form 1099-DIV with the IRS for 

each of the other owners to show their share of the income, and you must 

furnish a Form 1099-DIV to each. A husband or wife is not required to file a 

nominee return to show amounts owned by the other. See the 2011 General

Instructions for Certain Information Returns. 
VOID CORRECTED

OMB No. 1545-0110 

2011

Form 1099-DIV 

Dividends and 

Distributions 

Copy C 

For Payer 

For Privacy Act 

and Paperwork 

Reduction Act 

Notice, see the 

2011 General 

Instructions for 

Certain 

Information 

Returns. 

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

PAYER’S federal identification 

number 

RECIPIENT’S identification 

number 

RECIPIENT’S name 

Street address (including apt. no.) 

City, state, and ZIP code 

Account number (see instructions) 2nd TIN not. 

1a Total ordinary dividends 

$ 

1b Qualified dividends

$ 

2a Total capital gain distr.

$ 

2b Unrecap. Sec. 1250 gain 

$ 

2c Section 1202 gain 

$ 

2d Collectibles (28%) gain 

$ 

3 Nondividend distributions 

$ 

4 Federal income tax withheld 

$ 

5 Investment expenses 

$ 

6 Foreign tax paid 

$ 

7 Foreign country or U.S. possession 

8 Cash liquidation distributions 

$ 

9 Noncash liquidation distributions 

$ 

Form 1099-DIV Department of the Treasury - Internal Revenue Service
Instructions for Payer 

General and specific form instructions are provided as 

separate products. The products you should use to 

complete Form 1099-DIV are the 2011 General 

Instructions for Certain Information Returns and the 

2011 Instructions for Form 1099-DIV. 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. Furnish Copy B of this form to the recipient 

by January 31, 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. 

Foreign dividend recipient. If the recipient of the 

dividend is a nonresident alien, you may have to 

withhold federal income tax and file Form 1042-S, 

Foreign Person’s U.S. Source Income Subject to

Withholding. See the Instructions for Form 1042-S and 

Pub. 515, Withholding of Tax on Nonresident Aliens and 

Foreign Entities. 

Need help? If you have questions about reporting on 

Form 1099-DIV, 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.