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 - Internal Revenue ServiceCat. No. 35115M

Form 1099-CAP

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

Copy A

For

Internal Revenue

Service Center

File with Form 1096.

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2004 General

Instructions for

Forms 1099, 1098,

5498, and W-2G.

Changes in

Corporate

Control and

Capital Structure

5

Date of sale or exchange

Aggregate amount received

Account number (optional)

3 No. of shares exchanged

Check the box if shareholder cannot take a loss on

their tax return based on the amount in box 2

2004

$

4 Classes of stock exchanged

6
CORRECTED (if checked)

Copy B

For Shareholder

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

taxable income results

from this transaction

and the IRS determines

that it has not been

reported.

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

Changes in

Corporate

Control and

Capital Structure

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 received

Account number (optional)

3 No. of shares exchanged

If this box is checked, you cannot take a loss on

your tax return based on the amount in box 2

2004

$

4 Classes of stock exchanged

6
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, if Box 6 is checked, you cannot

take a (loss) on your tax return as a result of this

exchange. Do not report this loss on Schedule D

(Form 1040).

Box 3. Shows the number of shares of the

corporation’s stock that you held which were

exchanged in the transaction.

Box 1. Shows the date the stock was exchanged for

cash, stock, or other property.

Box 4. Shows the class or classes of stock that were

exchanged.

Box 2. Shows the aggregate amount of any cash and

other property received in the exchange for the stock

you held.
VOID CORRECTED

For Corporation

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2004 General

Instructions for

Forms 1099,

1098, 5498,

and W-2G.

Copy C

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

Changes in

Corporate

Control and

Capital Structure

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 received

Account number (optional)

3 No. of shares exchanged

Check the box if shareholder cannot take a loss on

their tax return based on the amount in box 2

2004

$

4 Classes of stock exchanged

6
Instructions for Corporations

General and specific form instructions are provided as

separate products. The products you should use for

2004 are the General Instructions for Forms 1099,

1098, 5498, and W-2G and the 2004 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, call 1-800-TAX-FORM

(1-800-829-3676).

Due dates. Generally, furnish Copy B of this form to

the shareholder by January 31, 2005. However, if the

recipient is a clearing organization, furnish Copy B by

January 5, 2005.

File Copy A of this form with the IRS by February 28,

2005. If you file electronically, the due date is March

31, 2005.

Caution: Because paper forms are scanned during

processing, you cannot file with the IRS Forms 1096,

1098, 1099, or 5498 that you print from the IRS

website.