C voip

LJ correcTeD

PAYER'S name, street address, city, state, and ZIP code

1a Gross dividends and other
distributions on stock (Total
of 1b, 1c, 1d, and le)

OMB No. 1545-0110

Dividends and

$ 1990 istributi
Distributions
1b Ordinary dividends
Statement for
$ Recipients of
PAYER'S Federal identification number | RECIPIENT'S identification number | 1¢ Capital gain distributions | 1d Nontaxable distributions Copy C

$

$ For Payer

RECIPIENT'S name

Je Investment expenses

2. Federal income tax withheld
For Paperwork

Reduction Act

$ $ Notice and

Street address 3 Foreign tax paid 4 Foreign country or U.S. possession instructions for
$ completing this

City, state, and ZIP code 1 form, Sor
+ SteKe ibuti instructions for
Liquidation Distributions Forms 1099,

‘Account number (optional) 5 Cash 6 Noncash (Fair market value)| 1098, 5498,
$ $ and W-2G.

Form 1099-DIV

DO voip

Department of the Treasury Internal Revenue Service

LJ coRRECTED

PAYER'S name, street address, city, state, and ZIP code

la Gross dividends and other
distributions on stock (Total
of 1b, 1¢, 1d, and le)

$

OMB No. 1545-0110

1990

Dividends and

Distributions
1b Ordinary dividends
Statement for
$ Recipients of
PAYER'S Federal identification number | RECIPIENT'S identification number 1c Capital gain distributions 1d_ Nontaxable distributions Copy Cc
$ $ For Payer
RECIPIENT'S name le Investment expenses 2 Federal income tax withheld
For Paperwork
Reduction Act
$ $ Notice and
Street address 3 Foreign tax paid 4 Foreign country or U.S. possession instructions for
$ completing this
City, state, and ZIP cod form, see
ity, state, and ZIP code beth ti ions f
Liquidation Distributions Instructions for
4 Forms 1099,
‘Account number (optional) 5 Cash ] 6 Noncash (Fair market value) 1098, 5498,
$ | and W-2G.

Form 1099-DIV

C1 voip

Department of the Treasury Internal Revenue Service

CJ correcTEeD

PAYER’S name, street address, city, state, and ZIP code

Ja Gross dividends and other
distributions on stock (Total
of 1b, 1c, 1d, and le)

$

OMB No. 1545-0110

Dividends and

1990

Distributions
1b Ordinary dividends
Statement for
$ Recipients of
PAYER’S Federal identification number | RECIPIENT'S identification number | 1¢ Capital gain distributions | 1d. Nontaxable distributions Copy C
$ $ For Payer
RECIPIENT'S name Je Investment expenses 2 Federal income tax withheld
For Paperwork
Reduction Act
$ $ Notice and
Street address 3 Foreign tax paid 4 Foreign country or U.S. possession instructions for
$ completing this
City, state, and ZIP form, see
ity, state, and ZIP code sauidation Di
» Liquidation Distributions Instructions for
Forms 1099,
Account number (optional) 5 Cash 6 Noncash (Fair market value)| 1098, 5498,
$ $ and W-2G.

Form 1099-DIV

Denartment of the Treasury Internal Revenue Service


Instructions for Recipient

Box 1a.—Gross dividends include any amounts shown in Boxes 1b,
Ic, 1d, and 1e. If you file Form 1040A, report the sum of Boxes 1b
and le. If you file Schedule B (Form 1040), to report dividends,
report Box 1a on Schedule B. If you file Form 1040 without Schedule
B, report the sum of Boxes 1b and le on the “Dividend income” line
and Box 1c on Schedule D (Form 1040) or the “Capital gain
distributions” line.

The amount shown may be a distribution from an employee stock
ownership plan (ESOP). Although you should report the ESOP
distribution as a dividend on your income tax return, treat it as a plan
distribution, not as investment income, for any other purpose.

Box 1b.—Ordinary dividends are fully taxable and are included

in Box la.

Box.1¢c.—Capital gain distributions are included in Box 1a.

Box 1d.—Amounts shown are usually a return of capital that reduce
your basis in the stock. Once you have received an amount equal to
your cost or other basis, these distributions are taxable to you as a
capital gain even if the payer lists them as nontaxable. This amount is
included in Box 1a. For more information, see Pub. 550, Investment
Income and Expenses.

Box le.—Any amount shown is your share of the expenses of a
nonpublicly offered regulated investment company, generally a
nonpublicly offered mutual fund, which ts included as a dividend in

Instructions for Recipient

Box la.—Gross dividends include any amounts shown in Boxes 1b,
1c, 1d, and le. If you file Form 1040A, report the sum of Boxes 1b
and le. If you file Schedule B (Form 1040), to report dividends,
report Box 1a on Schedule B. If you file Form 1040 without Schedule
B, report the sum of Boxes 1b and le on the “Dividend income” line
and Box 1c on Schedule D (Form 1040) or the “Capital gain
distributions” line.

The amount shown may be a distribution from an employee stock
ownership plan (ESOP). Although you should report the ESOP
distribution as a dividend on your income tax return, treat it as a plan
distribution, not as investment income, for any other purpose.

Box 1b.—Ordinary dividends are fully taxable and are included

In Box la.

Box 1c.—Capital gain distributions are included in Box la.

Box 1d.—Amounts shown are usually a return of capital that reduce
your basis in the stock. Once you have received an amount equal to
your cost or other basis, these distributions are taxable to you as a
capital gain even if the payer lists them as nontaxable. This amount is
included in Box 1a. For more information, see Pub. 550, Investment
Income and Expenses.

Box 1e.—Any amount shown is your share of the expenses of a
nonpublicly offered regulated investment company, generally a
nonpublicly offered mutual fund, which ts included as a dividend in

Instructions for Recipient

Box 1a.—Gross dividends include any amounts shown in Boxes 1b,
1c, 1d, and 1e. If you file Form 1040A, report the sum of Boxes 1b
and le. If you file Schedule B (Form 1040), to report dividends,
report Box 1a on Schedule B. if you file Form 1040 without Schedule
B, report the sum of Boxes 1b and 1e on the “Dividend income” line
and Box 1c on Schedule D (Form 1040) or the “Capital gain
distributions” line.

The amount shown may be a distribution from an employee stock
ownership plan (ESOP). Although you should report the ESOP
distribution as a dividend on your income tax return, treat it as a plan
distribution, not as investment income, for any other purpose.

Box 1b.—Ordinary dividends are fully taxable and are included

in Box la.

Box 1¢.—Capital gain distributions are included in Box 1a.

Box 1d.—Amounts shown are usually a return of capital that reduce
your basis in the stock. Once you have received an amount equal to
your cost or other basis, these distributions are taxable to you as a
capital gain even if the payer lists them as nontaxable. This amount is
included in Box 1a. For more information, see Pub. 550, Investment
Income and Expenses.

Box 1e.—Any amount shown 1s your share of the expenses of a
nonpublicly offered regulated investment company, generally a
nonpublicly offered mutual fund, which 1s included as a dividend in

Box 1a. The full amount shown in Box 1a must be reported as income
on your tax return. The expenses shown in Box le are deductible as a
“Miscellaneous Deduction” on Schedule A (Form 1040) subject to the
2% limit. Generally, the actual amount you should have received or
had credited to you 1s the amount in Box 1a less the amount in Box le.
Box 2.—Shows backup withholding. For example, persons not
furnishing their taxpayer identification number to the payer become
subject to backup withholding at a 20% rate on certain payments. 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.

Box 3.—You may elect to claim the amount shown as a deduction or a
credit. See Pub. 514, Foreign Tax Credit for Individuals.
Nominees.—If your Federal identification number ts shown on this
form and the form includes amounts belonging to another person, you
are considered a nominee recipient. You must file Form 1099-DIV for
each of the other owners showing the income allocable to each, and
you must furnish a Form 1099-DIV to each. File Form(s) 1099-DIV
with Form 1096, Annual Summary and Transmittal of U.S.
Information Returns, at the Internal Revenue Service Center for your
area. On each Form 1099-DIV, list yourself as the “payer” and the
other owner as the “recipient.” On Form 1096, list yourself as the
“filer.” A husband or wife ts not required to file a nominee return to
show payments owned by the other.

4ULS. GOVERNMENT PRINVING OFFICE. 1989-245-239

Box 1a. The full amount shown in Box 1a must be reported as income
on your tax return. The expenses shown in Box le are deductible as a
“Miscellaneous Deduction” on Schedule A (Form 1040) subject to the
2% limit. Generally, the actual amount you should have received or
had credited to you ts the amount in Box 1a less the amount in Box le.
Box 2.—Shows backup withholding. For example, persons not
furnishing their taxpayer identification number to the payer become
subject to backup withholding at a 20% rate on certain payments. 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.

Box 3.—You may elect to claim the amount shown as a deduction or a
credit. See Pub. 514, Foreign Tax Credit for Individuals.
Nominees.—If your Federal identification number 1s shown on this
form and the form includes amounts belonging to another person, you
are considered a nominee recipient. You must file Form 1099-DIV for
each of the other owners showing the income allocable to each, and
you must furnish a Form 1099-DIV to each. File Form(s) 1099-DIV
with Form 1096, Annual Summary and Transmittal of U.S.
Information Returns, at the Internal Revenue Service Center for your
area. On each Form 1099-DIV, list yourself as the “payer” and the
‘other owner as the “recipient.” On Form 1096, list yourself as the
“filer.” A husband or wife 1s not required to file a nominee return to
show payments owned by the other.

*ULS. GOVERNMENT PRINTING OFFICE. 1989-245-230

Box 1a. The full amount shown in Box 1a must be reported as income
‘on your tax return. The expenses shown in Box le are deductible as a
“Miscellaneous Deduction” on Schedule A (Form 1040) subject to the
2% limit. Generally, the actual amount you should have received or
had credited to you 1s the amount in Box 1a fess the amount in Box le.
Box 2.—Shows backup withholding. For example, persons not
furnishing their taxpayer identification number to the payer become
subject to backup withholding at a 20% rate on certain payments. 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.

Box 3.—You may elect to claim the amount shown as a deduction or a
credit. See Pub. 514, Foreign Tax Credit for Individuals.
Nominees.—If your Federal identification number ts shown on this
form and the form includes amounts belonging to another person, you
are considered a nominee recipient. You must file Form 1099-DIV for
each of the other owners showing the income allocable to each, and
you must furnish a Form 1099-DIV to each. File Form(s) 1099-DIV
with Form 1096, Annual Summary and Transmittal of U.S.
Information Returns, at the Internal Revenue Service Center for your
area. On each Form 1099-DI, list yourself as the “payer” and the
other owner as the “recipient.” On Form 1096, list yourself as the
“filer.” A husband or wife 1s not required to file a nominee return to
show payments owned by the other.

*U.S. GOVERNMENT PRINTING OFFICE. 1989-245-230


9191 (vow

CJ correcTeD

‘Type or machine print PAYER’S name, street address, city, state, and ZIP code

1a Gross dividends and other
distributions on stock (Total
of 1b, 1c, 1d, and le)

$

1b Ordinary dividends

OMB No. 1545-0110

1990

Statement for

$ Recipients of
PAYER'S Federal identification number | RECIPIENT'S identification number | 1¢ Capital gain distributions | 1d. Nontaxable distributions Copy A
$ For Internal
‘Type or machine print RECIPIENT'S name Je Investment expenses 2 Federal income tax withheld Revenue
Service Center
For Paperwork
$ $ 4 Reduction Act
Street address 3 Foreign tax paid “Foreign country or US. poseessica Notice and
instructions for
City ata 7 completing this
‘ity, state, and ZIP code beat, Py 7 form, see
Liquidation Distributions Instructions for
‘Account number (optional) 5 Cash 6 _Noncash (Fair market value) Forms 1098.
$ $ and W-2G.

Form 1099-DIV

Do NOT Cut or Separate Forms on This Page

Department of the Treasury - Internal Revenue Service

4191 Cvow Ei correcteo
Type or machine print PAYER’S name, street address, city, state, and ZIP code | 1a Gross dividends and other | OMB No. 1545-0110
distributions on stock (Total
of 1b, 1c, 1d, and le) Dividends and
s 1990 Distributions
1b Ordinary dividends
Statement for
$ Recipients of
PAYER'S Federal identification number | RECIPIENT'S identification number 1c Capital gain distributions 1d_ Nontaxable distributions Copy A
$ For Internal
Type or machine print RECIPIENT'S name Te Investment expenses 2 Federal income tax withheld Revenue
Service Center
For Paperwork
s § Reduction Act
Street address 3 Foreign tax paid Foreign country or US. possession Notice and
instructions for
City state TP cod completing this
‘ity, state, and ZIP code bees, Setril
” Liquidation Distributions I stra See
‘Account number (optional) 5 Cash 6 _Noncash (Fair market value) Foums 2088
$ $ and W-2G.

Form 1099-DIV

Do NOT Cut or Separate Forms on This Page

CI corRECTED

Department of the Treasury - Internal Revenue Service

9191 CO) voio
“Type or machine print PAYER’S name, street address, city, state, and ZIP code | 1a Gross dividends and other | OMB No. 1545-0110
distributions on stock (Total
of 1b, 1c, 1d, and Le) Dividends and
s 1990 Distributions
1b Ordinary dividends
Statement for
$ Recipients of
PAYER'S Federal identification number] RECIPIENT'S identification number | 1¢ Capital gain distributions | 1d. Nontaxable distributions Copy A
$ $ For Internal
‘Type or machine print RECIPIENT'S name Te Investment expenses 2 Federal income tax withheld Revenue
Service Center
For Paperwork
§ $ Reduction Act
Street address 3 Foreign tax paid “Foreign country ar U.S. possession Notice and
$ instructions for
Ci completing this
ity, state, and ZIP code .
i Liquidation Distributions \ stra ee
‘Account number (optional) 5 Cash @ _ Noncash (Fair market value) Founs 2028.
$ $ and W-2G.

Form 1099-DIV

Department of the Treasury - Internal Revenue Service




(J CORRECTED (if checked)

PAYER’S name, street address, city, state, and ZIP code Ta Gross dividends and other | OMB No. 1545-0110
distributions on stock (Total
of 1b, 1c, 1d, and le) Dividends and
$ 1990 Distributions
1b Ordinary dividends
Statement for
$ Recipients of
PAYER'S Federal identification number | RECIPIENT'S identification number le Capital gain distributions 1d Nontaxable distributions Copy B
$ $ For Recipient
RECIPIENT'S name le Investment expenses 2 Federal income tax withheld This is important tax
information and is.
being furnished to the
$ $ Internal Revenue
Street address 3 Foreign tax paid 4 Foreen country or US possess00 | ay soarmce. Ifyou are
$ a negligence penalty or
City, state, and ZIP code other sanction may be
ity, state, ion Distributi imposed on you if this
Liquidation Distributions posed on you i this
‘Account number (optional) 5 Cash [6 Noncash Fair market value)] 4 enable ana tne IRS
$ $ not been reported.
Form 1099-DIV Department of the Treasury - Internal Revenue Service
LJ CORRECTED (if checked)
PAYER'S name, street address, city, state, and ZIP code la Gross dividends and other OMB No. 1545-0110
distributions on stock (Total
of 1b, 1c, 16, and le) Dividends and
§ 1990 Distributions
1b Ordinary dividends
Statement for
$ Recipients of
PAYER’S Federal identification number | RECIPIENT'S identification number 1c Capital gain distributions: 1d_ Nontaxable distributions Copy B

$

RECIPIENT'S name

e Investment expenses

2 Federal income tax withheld

For Recipient
This 1s 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
dividend income is

$ $
Street address 3 Foreign tax paid ‘4 Foreign country or U.S. possession
$
City, state, and ZIP code 5 sont 1
% Liquidation Distributions
Account number (optional) 5 Cash 6 Noncash (Fair market value)|
$ $

taxable and the IRS
determines that it has

not been reported.

Form 1099-DIV

Department of the Treasury

C1 CORRECTED (if checked)

PAYER’S name, street address, city, state, and ZIP code

a Gross dividends and other
distributions on stock (Total
of 1b, 1c, 16, and le)

1b Ordinary dividends

‘OMB No. 1545-0110

1990

- Internal Revenue Service

Dividends and
Distributions

Statement for

$ Recipients of
PAYER'S Federal identification number } RECIPIENT'S identification number 1c Capital gain distributions 1d_ Nontaxable distributions Copy B
$ For Recipient
RECIPIENT'S name le Investment expenses 2 Federal income tax withheld This is important tax
information and 1s
being furnished to the
$ $ internal Revenue

i

Street address 3 Foreign tax paid Foreign country or US. possession Service. Ifyou are

City, state, and ZIP code

required to file a return,
‘a negligence penalty or

Liquidation Distributions

other sanction may be
imposed on you if this,
dividend income is

‘Account number (optional)

5 Cash

6 Noncash (Fair market value)|

$

taxable and the IRS
determines that it has
not been reported.

Form 1099-DIV

Department of the Treasury

Internal Revenue Service