{_] voip {_] CORRECTED

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

1 Gross dividends and other | OMB No.1545-0110

distributions on stock

PAYERS Federal identification number | RECIPIENT'S identification number

1985 Dividends and
Distributions
2 Dividends qualifying for exclusion Statement for
Recipients of
3 Dividends not qualifying for | 4 Federal income tax withheld
exclusion Copy C
For Payer

RECIPIENT'S name (first, middle, last)

Street address

City, state, and ZIP code

5 Capital gain distributions 6 Nontaxable distributions (if

determmable)

For Paperwork
Reduction Act
Notice and

7 Foreign tax paid 8 Foreign country or U.S. possession

instructions for
completing this

Liquidation Distributions

form, see
Instructions for

‘Account number (optional)

9 Cash 10 Noneash (Fair market value)

Form 1099
Series, 1098,
5498, and 1096.

Form 1099-DIV

[Jvoio —[]CoRRECTED

Department of the Treasury

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

1 Gross dividends and other
distributions on stock

OMB No.1545-0110

1985

Internal Revenue Service

Dividends and

PAYER’S Federal identification number | RECIPIENT'S identification number

Distributions
2 Dividends qualifying ‘or exclusion | Statement for
Recipients of
3 Dividends not qualifying for 4 Federal income tax withheld
exclusion Copy C
For Payer

RECIPIENT'S name (first, middle, last)

Street address

City, state, and ZIP code

5 Capital gain distributions 6 Nontaxable distributions (if

determinable)

For Paperwork
Reduction Act
Notice and

7 Foreign tax paid 8 Foreign country or U.S. possession

instructions for
completing this
form, see

Liquidation Distributions

Instructions for

‘Account number (optional)

9 Cash 10 Noncash (Fair market value)

Form 1099
Series, 1098,
5498, and 1096.

Form 1099-DIV

[| voip {J CORRECTED

Department of the Treasury

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

OMB No.1545-0110

1985

1 Gross dividends and other
distributions on stock

2 Didends quaityng forexcusion | Statement for

Recipients of

Internal Revenue Service

Dividends and
Distributions

PAYERS Federal ide

fication number | RECIPIENT'S identification number

3 Dividends not qualifying for | 4 Federal income tax withheld

exclusion

Copy C
For Payer

RECIPIENT'S name (first, middle, last)

Street address

City, state, and ZIP code

5 Capital gain distributions 6 Nontaxable distributions (if

determinable)

For Paperwork
Reduction Act
Notice and

7 Foreign tax paid 8 Foreign country or U.S. possession

instructions for
completing this
form, see

Liquidation Distributions

Instructions for

Account number (optional)

9 Cash 110 Noncash (Fair market value)

Form 1099
Series, 1098,
5498, and 1096.

Form 1099-DIV

Department of the Treasury

Internal Revenue Service


Instructions for Recipient

The amount listed in Box 2 is the amount of dividends that
qualifies for the dividend exclusion. You are allowed an
exclusion of $100 ($200 in the case of a joint return) of the
total of the amounts received during the tax year as
qualifying dividends.

Report the amount shown in Box 1 on the Dividends line of
your income tax return. Then use the amount in Box 2 to
arrive at the proper amount of the exclusion for the year.
See the instructions for your income tax return for more
information on how to report the income and take the
exclusion.

If you receive dividends from a regulated investment
company (including money market funds), the company
will tell you if any portion qualifies for the exclusion.

Any amount shown in Box 4 represents 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, Payer’s Request for Taxpayer Identification

Instructions for Recipient

The amount listed in Box 2 is the amount of dividends that
qualifies for the dividend exclusion. You are allowed an
exclusion of $100 ($200 in the case of a joint return) of the
total of the amounts received during the tax year as
qualifying dividends.

Report the amount shown in Box 1 on the Dividends line of
your income tax return. Then use the amount in Box 2 to
arrive at the proper amount of the exclusion for the year.
See the instructions for your income tax return for more
information on how to report the income and take the
exclusion

If you receive dividends from a regulated investment
company (including money market funds), the company
will tell you if any portion qualifies for the exclusion.

Any amount shown in Box 4 represents 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, Payer's Request for Taxpayer Identification

Instructions for Recipient

The amount listed in Box 2 is the amount of dividends that
qualifies for the dividend exclusion. You are allowed an
exclusion of $100 ($200 in the case of a joint return) of the
total of the amounts received during the tax year as
qualifying dividends.

Report the amount shown in Box 1 on the Dividends line of
your income tax return. Then use the amount in Box 2 to
arrive at the proper amount of the exclusion for the year.
See the instructions for your income tax return for more
information on how to report the income and take the
exclusion.

If you receive dividends from a regulated investment
company (including money market funds), the company
will tell you if any portion qualifies for the exclusion.

Any amount shown in Box 4 represents 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, Payer’s Request for Taxpayer Identification

Number and Certification, for information on backup
withholding. Include this on your income tax return as tax
withheld

Amounts listed in Box 6 as nontaxable distributions are
usually a return of capital. Once you have received an
amount equal to your cost, or other basis, these distributions
are taxable to you as capital gain distributions even if the
payer lists them as nontaxable. For more information, see
Publication 550, Investment income and Expenses

If this form shows two or more recipients, or if the amounts
shown include dividerds or distributions belonging to
another person, the recipient who is acting as a nominee
and whose Federal identification number is shown should
file a nominee form with the Internal Revenue Service to
show the proper distribution of the amounts shown. Use
another Form 1099-DIV, complete a Form 1096, Annual
Summary and Transmittal of U.S. Information Returns, and
file both forms with the Internal Revenue Service Center. A
husband or wife is not required to file a nominee return to
show payments for the other.

Number and Certification, for information on backup
withholding. Include tris on your income tax return as tax
withheld.

Amounts listed in Box 6 as nontaxable distributions are
usually a return of cay:ital. Once you have received an
amount equal to your cost, or other basis, these distributions
are taxable to you as capital gain distributions even if the
payer lists them as nontaxable. For more information, see
Publication 550, Investment Income and Expenses.

If this form shows two or more recipients, or if the amounts
shown include divider:ds or distributions belonging to
another person, the recipient who is acting as a nominee
and whose Federal identification number is s;own should
file a nominee form w'th the Internal Revenue Service to
show the proper distridution of the amounts shown. Use
another Form 1099-DIV, complete a Form 1096, Annual
Summary and Transmittal of U.S. Information Returns, and
file both forms with the Internal Revenue Service Center. A
husband or wife is not required to file a nominee return to
show payments for the other.

Number and Certifica ion, for information on backup
withholding. Include this on your income tax return as tax
withheld

Amounts listed in Box 6 as nontaxable distributions are
usually a return of capital. Once you have rec2ived an
amount equal to your “ost, or other basis, these distributions
are taxable to you as capital gain distributions even if the
payer lists them as nontaxable. For more information, see
Publication 550, Investment Income and Expenses.

If this form shows two or more recipients, or if the amounts
shown include dividends or distributions belonging to
another person, the recipient who is acting as a nominee
and whose Federal identification number is shown should
file a nominee form with the Internal Revenue Service to
show the proper distribution of the amounts shown. Use
another Form 1099-DIV, complete a Form 1096, Annual
Summary and Transmittal of U.S. Information Returns, and
file both forms with the Internal Revenue Service Center. A
husband or wife is not required to file a nominee return to
show payments for the other.


For Official Use Only

|: 1 Gross dividends and other |
distributions on stock

(OMB No.1545-0110

1985

Dividends and

enunemunaiin 2 Distributions
2 Dividends qualifying for exclusion ‘| Statement for
7 y | Recipients of
—————
13 Dividends not qualifying for _ Federal income tax withheld | Copy A
ORCIUSION ese / $e For Internal
Revenue

[ PAYERS Federal identification | " RECIPIENT'S identification number .
(

Service Center

For Paperwork
Reduction Act

Nontaxable distributions (if
determinable)

Notice and
instructions for
completing this

form, see

Instructions for
Form 1099
Series, 1098,

|] 5498, and 1096.

Do NOT Cut or Separate Forms on This Page

9191 For Official Use Only

Department of the Treasury - Internal Revenue Service

PAYER’S Federal identification number |. RECIPIENT'S identification number |

[ 1 Gross dividends and other | OMB No.1545-0110
a _fistributi si ck
“| 985 Dividends and
ae mene Distributions
2 Dividends quaifying forexclusion | S¢atement for
'|_Recipients of
= :

J Dividends not qualifying for a 4 Federal income tax withhel Copy A
eu aa For Internal
Revenue

“Type or machine print RECIPIENT'S name (first, middle, last)

Service Center
For Paperwork

— —_— Reduction Act
ee = se ~ Notice and
Street address *] 8 Foreign country or US. possession | — instructions for

completing this

form, see

‘Account number (optional)

Instructions for
Form 1099
Series, 1098,
|| 5498, and 1096.

Form 1089-DIV

Do NOT Cut or Separate Forms on This Page

CORRECTED For Official Use Only

Department of the Treasury - Internal Revenue Service

OMB No.1545-0110
1985 Dividends and
Distributions

Statement for

Reci| ients of
on

Dividends not qualifying for = CopyA
oe For Internal
Revenue

Service Center

For Paperwork
Reduction Act
Notice and

iG Nontaxable distributions cr
| determinable)

instructions for
completing this

form, see
Instructions for

Form 1099
Series, 1098,
5498, and 1096.

Form 1099-DIV

Department of the Treasury - Internal Revenue Service




(CORRECTED

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

1 Gross dividends and other
distributions on stock

OMB No. 1545-0110

PAYER’S Federal identification number | RECIPIENT'S identification number

1985 Dividends and
Distributions
2 Dividends qualityingtorexciusion | Statement for
Recipients of
3 Dividends not qualifying for | 4 Federal income tax withheld Copy B
exclusion

RECIPIENT'S name (first, middle, last)

Street address

City, state, and ZIP code

5 Capital gain distributions

6 Nontaxable distributions (if
determinable)

7 Foreign tax paid

& Foreign country or US. possession

Liquidation

Distributions

‘Account number (optional)

9 Cash

110 Noncash (Fair market value)

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 will be
imposed on you if
this dividend income
is taxable and the
IRS determines that
it has not been
reported

Form 1099-DIV

[I corRECTED

Department of the Treasury - Internal Revenue Service

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

1 Gross dividends and other

OMB No. 1545-0110

PAYER’S Federal identification number | RECIPIENT'S identification number

distributions on stock
1985 Dividends and
Distributions
2 Dividends qualifvingforexcusion | Statement for
Recipients of
3 Dividends not qualifying for 4 Federal income tax withheld Copy B
exclusion
For Recipient

RECIPIENT'S name (first, middle, last)

Street address

City, state, and ZIP code

'5 Capital gain distributions

6 Nontaxable distributions (if
determinable)

7 Foreign tax paid

‘8 Foreign country or US. possession

Liquidation Distributions

Account number (optional)

9 Cash

110 Noncash (Fair market value)

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 will be
imposed on you if
this dividend income
is taxable and the
IRS determines that
it has not been
reported.

Form 1099-DIV

(J CoRRECTED

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

1 Gross dividends and other
distributions on stock

OMB No.1545-0110

Department of the Treasury - Internal Revenue Service

PAYER'S Federal identification number | RECIPIENT'S identification number

1985 Dividends and

Distributions
2 Dividends qualitying forexclusion | Statement for
Recipients of

3 Dividends not qualifying for | 4 Federal income tax withheld Copy B

exclusion

RECIPIENT'S name (first, middle, last)

Street address

City, state, and ZIP code

5 Capital gain distributions

6 Nontaxable distributions (if
determinable)

7 Foreign tax paid

8 Foreign country or U.S. possession

Liquidation Distributions

‘Account number (optional)

9 Cash

110 Noncash (Fair market value)

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 will be
imposed on you if
this dividend income
is taxable and the
IRS determines that
it has not been
reported.

Form 1099-DIV

Department of the Treasury - Internal Revenue Service