Statement for

1976

Recipients of
‘Type or print a
PAYER'S Dividends and
name, address, eg op gs
Z1P code, and | Distributions
Federal
identifying Copy C
number. For Payer
Recipient's ider 1 Gross dividends and other dis- | 2 Dividends qualifying for | 3 Dividends not qualifying for | 4 Capital gain distributions
tributions on stock exe n

exclusion

Type or print RECIPIENT'S name, address, and ZIP code below.

5 Nontaxable distributions
(If determinable)

6 Foreign tax paid (If eligi-

7 Foreign Country or
ble for foreign tax credit)

U.S. Possession

Form 1099-DIV

3 GPO: 1975—-0-575-092 16—82648-1 Department of the Treasury—Internal Revenue Service

Statement for
Recipients of
‘Type or print a
PAYER'S Dividends and
name, address, eg op gs
Z1P code, and | Distributions
Federal
identifying Copy C
number. For Payer
Recipient's ider 1 Gross dividends and other dis- qualifying for | 3 Dividends not qualifying for | 4 Capital gain distributions
tributions on stock

exclusion

Type or print RECIPIENT'S name, address, and ZIP code below.

5 Nontaxable distributions

6 Foreign tax paid (If eligi-
(If determinable)

7 Foreign Country or
ble for foreign tax credit)

U.S. Possession

Form 1099-DIV e GPO: 1975~0-575-092 16—82648-1 Department of the Treasury—Internal Revenue Service
Statement for
Recipients of
‘Type or print —
PAYER'S Dividends and
name, address, eg op gs
Z1P 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 ion

exclusion

Type or print RECIPIENT'S name, address, and ZIP code below.

5 Nontaxable distributions
(If determinable)

6 Foreign tax paid (If eligi-

7 Foreign Country or
ble for foreign tax credit)

U.S. Possession

Form 1099-DIV

3 GPO: 1975—-0-575-092

16—82648-1 Department of the Treasury—Internal Revenue Service




10

For Official Use Only

Type or print
PAYER'S

Statement for
Recipients of

1976

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 | 4 Capital gain distributions
tributions on stock exclusion exclusion

Type or print RECIPIENT'S name, address, and ZIP code below (Name must aline

with arrow.)

Name p>]

5 Nontaxable distributions
(If determinable)

6 Foreign tax paid (If eli
ble for foreign tax credit)

7 Foreign Country or
U.S. Possession

For instructions on completing this form, see ‘Instructions
for Form 1096.”

“Form 1099-DIV

For Official Use Only

k GPO: 1975—-0-575-092

16—82648-1

Type or print
PAYER'S

Department of the Treasury—Internal Revenue Service

Statement for

Recipients of 1976

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 2 Dividends qualifying for J 3 idends not qualifying for | 4 Capital gain distributions

tributions on stock exclusion exclusion
10
Type or print RECIPIENT'S name, address, and ZIP code below (Name must aline [J 5 Nontaxable distributions | 6 Foreign tax paid (If eligi. | 7 Foreign Country or
ferminable) je for foreign tax credi 3. Possession
with arrow.) (If determinable) ble for fe te dit) U.S. Pe

Name p>]

10

Name p>]

For instructions on completing this form, see ‘‘Instructions
for Form 1096.""

“Form 1099-DIV

For Official Use Only

1 GPO: 1975—0-575-092

16—82648-1

Type or print
PAYER'S
name, address,
ZIP code, and
Federal
identifying
number.

Department of the Treasury—Internal Revenue Service

Statement for
Recipients of

1976

Dividends and
Distributions
Copy A

For Internal Revenue
Service Center

jent’s identifying number

1 Gross dividends and other dis-
tributions on stock

2 Dividends
exclusion

qualifying

for

3 Dividends not qualifying for

exclusion

4 Capital gain distributions

Type or print RECIPIENT'S name, address, and ZIP code below (Name must aline

with arrow.)

5 Nontaxable distributions
(If determinable)

6 Foreign tax paid (If eligi-
ble for foreign tax credit)

7 Foreign Country or
U.S. Possession

For instructions on completing this form, see ‘Instructions
for Form 1096.”

“Form 1099-DIV

k GPO: 1975—-0-575-092

16—82648-1

Department of the Treasury—Internal Revenue Service




Statement for

1976

Recipients of
Type or print| 9.
PAYER'S Dividends and
address, | pus gp ge
ZP code, ana’ | Distributions
Federal
identifying Copy B
number. For Recipient

Recipient's identifying number

1 Gross dividends and other dis-
tributions on stock

2 Dividends
exclusion

qualifying for | 3 Dividends not

exclusion

qualifying for | 4 Capital gain distributions

Type or print RECIPIENT'S name, address, and ZIP code below.

5 Nontaxable distributions
(If determinable)

7 Foreign Country or

6 Foreign tax paid (If eligi-
U.S. Possession

ble for foreign tax credit)

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
ach 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.

Form 1099-DIV

Ye GPO: 1515—-0-575-092

16—82648-1 Department of the Treasury—Internal Revenue Service

Statement for
Recipients of

Type or print 7

PAYER'S Dividends and

name, address, + ae .

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
(If determinable)

7 Foreign Country or

6 Foreign tax paid (If eligi-
U.S. Possession

ble for foreign tax credit)

If this form shows two or more recipients, the recipient whose Federal identifying
number is shown should file @ 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.

Form 1099-DIV GPO: 1975-0-575-092 106—82648-1 Department of the Treasury—Internal Revenue Service

Statement for
Recipients of

Type or print} |.

PAYER'S Dividends and

name, address, | rye gusp ge

ziP code, and | Distributions

Federal

identifying Copy B

number. For Recipient

Recipient's identifying number

1 Gross dividends and other dis-
tributions on stock

2 Dividends
exclusion

qualifying for | 3 Dividends not

exclusion

qualifying for | 4 Capital gain distributions

‘Type or print RECIPIENT'S name, address, and ZIP code below.

5 Nontaxable distributions
(If determinable)

7 Foreign Country or

6 Foreign tax paid (If eligi-
U.S. Possession

ble for foreign tax credit)

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
ach 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.

Form 1099-DIV

Ye GPO: 1515 —0-575-092

16—82648-1 Department of the Treasury—Internal Revenue Service