Unrecap. Sec. 1250 gain

VOID CORRECTED

PAYER’S name, street address, city, state, ZIP code, and telephone no. 1a Total ordinary dividends OMB No. 1545-0110

$

1b Qualified dividends

$

2a Total capital gain distr.

RECIPIENT’S identification

number

PAYER’S federal identification

number

RECIPIENT’S name Section 1202 gain 2c 2d Collectibles (28%) gain

$

3

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

City, state, and ZIP code

Noncash liquidation

distributions

Cash liquidation 9

distributions

Account number (see instructions) 8

$

$

2b

$ $

Nondividend distributions

Form 1099-DIV

Dividends and

Distributions

$

9191

2nd TIN not.

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

Copy A

File with Form 1096.

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2009 General

Instructions for

Forms 1099,

1098, 3921,

3922, 5498, and

W-2G.

For

Internal Revenue

Service Center

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

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

$

$

4 Federal income tax withheld

$

$

2009
CORRECTED (if checked)

PAYER’S name, street address, city, state, ZIP code, and telephone no.

RECIPIENT’S identification

number

PAYER’S federal identification

number

RECIPIENT’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (see instructions)

Dividends and

Distributions

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

Copy B

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.

For Recipient

Unrecap. Sec. 1250 gain

1a Total ordinary dividends OMB No. 1545-0110

$

1b Qualified dividends

$

2a Total capital gain distr.

2c Section 1202 gain 2d Collectibles (28%) gain

$

3

5 Investment expenses

Noncash liquidation

distributions

Cash liquidation 9

distributions

8

$

$

2b

$ $

Nondividend distributions

Form 1099-DIV

$

6 7

$

Foreign tax paid Foreign country or U.S. possession

$

$

4 Federal income tax withheld

$

2009
Box 1b. Shows the portion of the amount in box 1a that may be

eligible for the 15% or zero capital gains rates. See the Form

1040/1040A instructions for how to determine this amount. Report

the eligible amount on line 9b, Form 1040 or 1040A.

Box 1a. Shows total ordinary dividends that are taxable. Include this

amount on line 9a of Form 1040 or 1040A. Also, report it on

Schedule B (Form 1040) or Schedule 1 (Form 1040A), if required.

Instructions for Recipients

Box 4. Shows backup withholding. For example, a payer must

backup withhold on certain payments at a 28% 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.

Box 2a. Shows total capital gain distributions from a regulated

investment company or real estate investment trust. Report the

amounts shown in box 2a on Schedule D (Form 1040), line 13. But, if

no amount is shown in boxes 2c–2d and your only capital gains and

losses are capital gain distributions, you may be able to report the

amounts shown in box 2a on line 13 of Form 1040 (line 10 of Form

1040A) rather than Schedule D. See the Form 1040/1040A

instructions.

Box 2b. Shows the portion of the amount in box 2a that is

unrecaptured section 1250 gain from certain depreciable real

property. Report this amount on the Unrecaptured Section 1250

Gain Worksheet–Line 19 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 distributions as capital gains. See Pub. 550, Investment

Income and Expenses.

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

deduction or a credit on Form 1040. See the 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 2009 General Instructions for

Forms 1099, 1098, 3921, 3922, 5498, and W-2G.

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 1a.

Box 2d. Shows 28% rate gain from sales or exchanges of

collectibles. If required, use this amount when completing the 28%

Rate Gain Worksheet–Line 18 in the instructions for Schedule D

(Form 1040).

The amount shown may be dividends a corporation paid directly

to you as a participant (or beneficiary of a participant) in an

employee stock ownership plan (ESOP). Report it as a dividend on

your Form 1040/1040A but treat it as a plan distribution, not as

investment income, for any other purpose.

Account number. May show an account or other unique number the

payer assigned to distinguish your account.

Box 2c. Shows the portion of the amount in box 2a that is section

1202 gain from certain small business stock that may be subject to a

50% exclusion and certain empowerment zone business stock that

may be subject to a 60% exclusion. See the Schedule D (Form 1040)

instructions.

Box 7. This box should be left blank if a regulated investment

company reported the foreign tax shown in box 6.
PAYER’S name, street address, city, state, ZIP code, and telephone no.

RECIPIENT’S identification

number

PAYER’S federal identification

number

RECIPIENT’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (see instructions)

Dividends and

Distributions

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

Copy C

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2009 General

Instructions for

Forms 1099,

1098, 3921,

3922, 5498,

and W-2G.

For Payer

VOID CORRECTED

2nd TIN not.

Unrecap. Sec. 1250 gain

1a Total ordinary dividends OMB No. 1545-0110

$

1b Qualified dividends

$

2a Total capital gain distr.

2c Section 1202 gain 2d Collectibles (28%) gain

$

3

5 Investment expenses

Noncash liquidation

distributions

Cash liquidation 9

distributions

8

$

$

2b

$ $

Nondividend distributions

Form 1099-DIV

$

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

$

$

4 Federal income tax withheld

$

$

2009
Instructions for Payers

General and specific form instructions are provided as

separate products. The products you should use to

complete Form 1099-DIV are the 2009 General

Instructions for Forms 1099, 1098, 3921, 3922, 5498,

and W-2G and the 2009 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. To order these instructions and

additional forms, visit the IRS website at www.irs.gov

or call 1-800-TAX-FORM (1-800-829-3676).

Due dates. Furnish Copy B of this form to the

recipient by February 1, 2010.

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 Entities.

Caution: Because paper forms are scanned during

processing, you cannot file with the IRS Forms 1096,

1098, 1099, 3921, 3922, or 5498 that you print from

the IRS website. Need help? If you have questions about reporting on

Form 1099-DIV, call the information reporting customer

service site toll free at 1-866-455-7438 or

304-263-8700 (not toll free). For TTY/TDD equipment,

call 304-267-3367 (not toll free). File Copy A of this form with the IRS by 

March 1, 2010. If you file electronically, the due date is

March 31, 2010. To file electronically, you must have

software that generates a file according to the

specifications in Pub. 1220, Specifications for Filing

Forms 1098, 1099, 3921, 3922, 5498, and W-2G

Electronically. IRS does not provide a fill-in form

option.