Form 1099-DIV

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RECIPIENT’S identification

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PAYER’S federal identification

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RECIPIENT’S name Nondividend distributions 3

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Street address (including apt. no.)

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City, state, and ZIP code

Account number (see instructions)

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Cat. No. 14415N Department of the Treasury - Internal R

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9 Noncash liquidation distributions
RECIPIENT’S identification

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PAYER’S federal identification

number

RECIPIENT’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (see instructions)

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

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4 Federal income tax withheld

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

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

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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.

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withhold on certain payments at a 28% rate if you did not give 

identification number to the payer. See Form W-9, Request for 

Identification Number and Certification, for information on back

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

a credit on Form 1040. See the Form 1040 instructions.

Boxes 8 and 9. Shows cash and noncash liquidation distributio

Nominees. If this form includes amounts belonging to another 

considered a nominee recipient. You must file Form 1099-DIV w

each of the other owners to show their share of the income, an

furnish a Form 1099-DIV to each. A husband or wife is not requ

nominee return to show amounts owned by the other. See the 

Instructions for Certain Information Returns.

Box 5. Shows your share of expenses of a nonpublicly offered 

investment company, generally a nonpublicly offered mutual fun

Form 1040, you may deduct these expenses on the “Other exp

Schedule A (Form 1040) subject to the 2% limit. This amount is 

box 1a.

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.

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 c

reported the foreign tax shown in box 6.
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)

Form 1099-DIV Department of the Treasury - Internal R

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2nd TIN not.

Unrecap. Sec. 1250 gain

$

2a Total capital gain distr.

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$

5 Investment expenses

Cash liquidation distributions Noncash liquidation distributions

$

2b

$ $

Form 1099-DIV

8 9

$

$

4 Federal income tax withheld

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

$ $

Nondividend distributions

6

$

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

$
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 January 31, 2011.

Foreign dividend recipient. If the recipient 

dividend is a nonresident alien, you may hav

withhold federal income tax and file Form 10

Foreign Person’s U.S. Source Income Subje

Withholding. See the Instructions for Form 1

Pub. 515, Withholding of Tax on Nonresiden

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 rep

Form 1099-DIV, call the information reporting 

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

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

call 304-579-4827 (not toll free). The hours o

are Monday through Friday from 8:30 a.m. to

4:30 p.m., Eastern time.

File Copy A of this form with the IRS by

February 28, 2011. If you file electronically, the due

date is March 31, 2011. To file electronically, you must