7373VOID 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 Department of the Treasury - InCat. No. 35115M

Form 1099-CAP

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

F

Ca

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

2009
CORRECTED (if checked)

i

f

Form 1099-CAP (keep for your records) Department of the Treasury - In

Ca

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

2009
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 

corporation’s stock that you held which 

exchanged in the transaction.

Box 1. Shows the date the stock was e

cash, stock, or other property.

Box 4. Shows the class or classes of s

exchanged.

Box 2. Shows the aggregate amount o

the fair market value of any stock or ot

received by you in the exchange for the 

held.

Account number. May show an account or other

unique number the payer corporation assigned to

distinguish your account.
VOID CORRECTED

Form 1099-CAP Department of the Treasury - In

Ca

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

2009
Instructions for Corporations

General and specific form instructions are provided as

separate products. The products you should use for

2009 are the General Instructions for Forms 1099,

1098, 3921, 3922, 5498, and W-2G and the 2009

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 the IRS website

at www.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 February 1, 2010. However, if the

recipient is a clearing organization, furnish Copy B by

January 5, 2010.

File Copy A of this form with the IRS 

2010. If you file electronically, the due d

31, 2010. To file electronically, you mus

that generates a file according to the sp

Pub. 1220, Specifications for Filing For

3921, 3922, 5498, and W-2G Electronic

not provide a fill-in form option.

Caution: Because paper forms are scanned during

processing, you cannot file with the IRS Forms 1096,

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

the IRS website.

Need help? If you have questions abou

Form 1099-CAP, call the information re

customer service site toll free at 1-866-

304-263-8700 (not toll free). For TTY/TD

call 304-267-3367 (not toll free).