Statement for
Recipients of

Type or print _ ,
PAYER'S Dividends and
name, address, sth gt
ZP code, and | Distributions
Federal
identifying Copy C
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 ZIP code below. 5 Nontaxable distributions 6 Foreign tax paid (If eligi- 7 Foreign Country or
Alf di vinable) ble for foreign tax credit) U.S. Possession
i
Form 1099-DIV YeGPO: 1979-0-263-413 §8-040-1110 Department of the Treasury—-Internal Revenue Service
Statement for
Recipients of
‘Type or print ws
PAYER'S Dividends and
name, address, 8 bt he be
ZIP code, 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 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
Form 1099—DIV ‘GPO: 1979-0-283-413 58-040-1110 Department of the Treasury—internal Revenue Service

Statement for
Recipients of

Type or print

PAYER'S Dividends and
name, address,

Zip code, and | Distributions

Federal
identifying Copy C
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 oi stock exclusion exclusion
‘Type or print RECIPIENT'S name, address, and ZIP code below. 5 Nontaxable distributions | Foreign tax paid (If eligi- | 7 Foreign Country or
(If determinable) ble for foreign tax credit) U.S. Possession

Form 1099-DIV YGPO: 1979-0-283-413 586-040-1110 Department of the Treasury—Internal Revenue Service


o¢ in box 2 is the amount of dividends
r the $100 dividend exclusion ($200
3 the amount in pox 2 is less than $100
hath spouses own the stock on which the
id). then you do not qualify for the entire
ung your spouse had dividend income from
“ awned stock, you may each subtract up to
ever if you file a joint return. However,
> any acrt ot ine $100 exclusion not used by
< owned separately.

iu Had $309 in dividends and your spouse had
“ he subtracted. If all of the stock on which the
od had been held jointly, then you and
4 {$100 each

= 1 box 1 must be reported as dividend

tacoma,

Ag amount i
uses own the stock on which the
vou ac not quelify for the entire
ar spouse had dividend income from
ck, you muy e subtract up to
ij you file @ joint return. Lowever,
the SIC exclusion nut used by
d caparstely.
i 3300 in dividends and your spouse had
all or the stock on which the
' Id jointly, then you and
ch}.

in sek must be reported as dividend

ox 2 is the amount of dividends
2 $100 dividend excision ($200
snout in box 2 :s less than $100
houses own th ack on which the
ue you do not lify for the entire
ir Spouse had dividend income from
“ack, you may each subtract up to
ven if you file @ join? return. However,
t of the $100 exclusion not used by
4, awaed separately,

3; had $30C in dividends and your spouse had
¥ be subtracted, if ali of the steck on which the
was receives had been held jointly, then you and
sibtvact $200 ($100 each).

be reported as dividend

sit i pax foie



Statement for
For Official Use Only Recipients of
Type or print ivi
PAVER'S Dividends and
name, address, | Distributions
ZIP code, and
Federal Copy A
identifying For Internal Revenue
} number. Service Center
Recipient's Wentifying number J 1 Gross dividends and other dis- J 2 Dividends qualifying for f 3 Dividends not qualilying for f 4 Capital gain distributions
tributions on stock exclusion exclusion
1 C]
[ in " ine 5 Nontaxable distributions — | 6 Foreign tax paid (If eligi- | 7 Foreign Country or
Type or rat RECIPIENT'S name, address, and ZIP code below (Name must aline ff 5 Nontaxable distri Foran tax paid (it aliak: | 7 Foreign County
Name > r
For instructions on completing this form, see “Instructions
for Form 1096.”
Form 1099—DIV sxGPO: 1979-0-283-413 $8-040-1110 Department of the Treasury—Internal Revenue Service
Statement for
For Official Use Only Recipients of
Type or print | pyiyyi,
pes 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- J 2 Dividends qualifying for J 3 Dividends not qualifying for J 4 Capital gain distributions
tributions on stock exclusion exclusion
1 f
int rs it 5 Nontaxable di itions 6 Foreign tax paid (If cligi- | 7 Foreign Country or
“ype or pint RECIPIENT'S name, aGaess and ZIP code below ame must aie J Nani i Taig ae 0Ulah | 7 fei any
Name >
For instructions on completing this form, see “Instructions
E for Form 1096.”
Form 1099—DIV SxGPO: 1979-0-283-413 58-040-1110 Department of the Treasury—Internal Revenue Service
Statement for
For Official Use Only Recipients of
Type or print j
PAYERS Dividends and
name, address, | Distributions
ZIP code, and
Federal Copy A
identifying For Internal Revenue
umber. Service Center
Recipient's identifying number 1 Gross dividends and other dis- J 2 Dividends qualifying for [J 3 Dividends not qualifying for [J 4 Capital gain distributions
tributions on stock exclusion exclusion
10)
it " addre i 5 Nontaxable distributic 6 Foreign tax paid (If eligi- | 7 Foreign Country or
Type or print RECIPIENT'S name, address, and ZIP code below (Name must aline | § Nentayable distributions Foren fx pad Ci eligi | 7 Fovelgn County
Name >

For instructions on completing this form, see “Instructions
for Form 1091

Department of the Treasury—internal Revenue Service

Form 1099-DIV YvGPO: 1979-0-289-413 58-041




Statement for
Recipients of
Type or print

PAYER'S Dividends and

name, address,

ziP code, and | Distributions

Federal
identifying Copy B
number. For Recipient

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 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 identi
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.

*Pleaso see note an back of this conv.

Form 1099-—DIV GPO: 1979-0-289-413 §8-040-1110 Department of the Treasury—inlernal Revenue Service

Statement for

Recipients of 1979
Dividends and

Zip code, and | Distributions

Federal

identifying Copy B
number. For Recipient

PAYER'S

7
‘Type or print |
name, address, |

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 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~D1V to show payments for the’ other.

This information is being furnished to the Internal Revenue Service.
*Please see note on hack of this copy.

Forn 1099—DIV YGPO: 1979-0-283-413 §8-040-1110 Department of the Treasury—Internal Revenue Service

Statement for
Recipients of
‘Type or print

PAYER'S Dividends and
name, address,

ZIP code, and | Distributions
Federal

identifying Copy B

number. For Recipient

's identifying number 1 Gross dividends and other dis- | 2 Dividends qualifying for | 3 Dividends not qualitying for | 4 Capital gain distributions
tributions on stock exclusion® 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 paymenis for the’ other.

This information is being furnished to the Internal Revenue Service.
Please see note on back of this copy.

Form 1099—DIV 3eGPO: 1979-0-283-413 58-040-1110 Department of the Treasury—internal Revenue Service