9191 VOID CORRECTED

4 Federal income tax withheld

PAYER’S name, street address, city, state, ZIP code, and telephone no. OMB No. 1545-0110

Dividends and

Distributions

$

2a Total capital gain distr.

PAYER’S Federal identification number RECIPIENT’S identification number 2d Unrecap. sec. 1250 gain

$ $

Qualified 5-year gain

3

2c

RECIPIENT’S name Nontaxable distributions

$ $

Section 1202 gain

Street address (including apt. no.) 5 Investment expenses

2e

$

City, state, and ZIP code

Account number (optional) 2nd TIN not. Noncash liquidation distr. 8 Cash liquidation distr. 9

$ $

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

$ Form 1099-DIV

6 Foreign tax paid 7 Foreign country or U.S. possession

$

$

1 Ordinary dividends

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

$

2b 28% rate gain

2001

Copy A

For

Internal Revenue

Service Center

File with Form 1096.

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2001 General

Instructions for

Forms 1099, 1098,

5498, and W-2G.
CORRECTED (if checked)

PAYER’S name, street address, city, state, ZIP code, and telephone no. OMB No. 1545-0110

Dividends and

Distributions

PAYER’S Federal identification number RECIPIENT’S identification number

RECIPIENT’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (optional)

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

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.

(Keep for your records.)

Form 1099-DIV

4 Federal income tax withheld

$

8 Cash liquidation distr.

$

6 Foreign tax paid

$

3 Nontaxable distributions

$

5 Investment expenses

9 Noncash liquidation distr.

$

7 Foreign country or U.S. possession

$

$

2a Total capital gain distr.

2d Unrecap. sec. 1250 gain

$ $

2c Qualified 5-year gain

$

2e Section 1202 gain

$

1 Ordinary dividends

$

2b 28% rate gain

2001
Instructions for Recipient

Box 1. Ordinary dividends, which include any net short-term capital gains from

a mutual fund, are fully taxable. Include this amount on the “Ordinary

dividends” line of Form 1040 or 1040A. Also report it on Schedule B (Form

1040) or Schedule 1 (Form 1040A), if required. This amount includes any

amount shown in box 5. Box 4. Shows backup withholding. For example, a payer must backup

withhold on certain payments at a 31% rate 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.

The amount shown may be a distribution from an employee stock

ownership plan (ESOP). Report it as a dividend on your income tax return, but

treat it as a plan distribution, not as investment income, for any other purpose.

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 1.

Box 2a. Shows total capital gain distributions (long-term) from a regulated

investment company or real estate investment trust. Amounts shown in boxes

2b, 2c, 2d, and 2e are included in box 2a. Report the amount in box 2a on

Schedule D (Form 1040), Part II. But, if no amount is shown in boxes 2b–2e

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

be able to report the amount in box 2a on the “Capital gain or (loss)” line of

Form 1040 or on the “Capital gain distributions” line of Form 1040A rather

than on Schedule D (Form 1040). See the Form 1040 or 1040A instructions.

Box 2b. Shows 28% rate gain from sales or exchange of collectibles. Report

this amount on Schedule D (Form 1040), Part II.

Box 2d. Shows unrecaptured section 1250 gain from certain depreciable real

property. Report this amount on the Unrecaptured Section 1250 Gain

Worksheet in the Schedule D instructions (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 nontaxable distributions as

capital gains, even though this form shows them as nontaxable. See Pub. 550,

Investment Income and Expenses.

Box 2e. Shows section 1202 gain from certain small business stock that may

be subject to a 50% exclusion. See the Schedule D (Form 1040) instructions.

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

credit on Form 1040. See your Form 1040 instructions.

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 2001 General

Instructions for Forms 1099, 1098, 5498, and W-2G.

Box 2c. Shows qualified 5-year gain that may be taxed at an 8% capital gains

rate. Report this amount on Schedule D (Form 1040). See the Schedule D

(Form 1040) instructions.
VOID CORRECTED

PAYER’S name, street address, city, state, ZIP code, and telephone no. OMB No. 1545-0110

Dividends and

Distributions

PAYER’S Federal identification number RECIPIENT’S identification number

RECIPIENT’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (optional) 2nd TIN not.

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

Copy C

For

Payer

Form 1099-DIV

4 Federal income tax withheld

$

8 Cash liquidation distr.

$

6 Foreign tax paid

$

3 Nontaxable distributions

$

5 Investment expenses

9 Noncash liquidation distr.

$

7 Foreign country or U.S. possession

$

$

2a Total capital gain distr.

2d Unrecap. sec. 1250 gain

$ $

2c Qualified 5-year gain

$

2e Section 1202 gain

$

1 Ordinary dividends

$

2b 28% rate gain

2001

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2001 General

Instructions for

Forms 1099,

1098, 5498,

and W-2G.
Payers, Please Note—

To help make it easier for you to get only the

information you need to complete the Forms 1099,

1098, 5498, and W-2G you file, we provide general

and specific form instructions as separate products.

The products you should use for 2001 are the General

Instructions for Forms 1099, 1098, 5498, and W-2G,

which contain general information concerning Form

1099-DIV and other forms in the 1099 series, and the

separate specific instructions for each information

return you file. Specific information needed to

complete this form is given in the 2001 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. You can order these

instructions and additional forms by calling

1-800-TAX-FORM (1-800-829-3676). You can also get

forms and instructions from the IRS’s Internet Web Site

at www.irs.gov.

Due dates. Furnish Copy B of this form to the

recipient by January 31, 2002.

File Copy A of this form with the IRS by February

28, 2002. If you file electronically, the due date is

April 1, 2002.

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 Corporations.

Caution: Because the IRS processes paper forms by

machine (optical character recognition equipment), you

cannot file with the IRS Forms 1096, 1098, 1099, or

5498 that you print from the IRS’s Internet Web Site.