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 (optional) 8

$

$

2b

$ $

Nontaxable 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

2004 General

Instructions for

Forms 1099,

1098, 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

$

$

2004
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 (optional)

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

$ $

Nontaxable distributions

Form 1099-DIV

$

6 7

$

Foreign tax paid Foreign country or U.S. possession

$

$

4 Federal income tax withheld

$

2004
Box 1b. Shows the portion of the amount in box 1a that may be

eligible for the 15% or 5% 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 to 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 Box 2a. Shows total capital gain distributions (long-term) from a income tax return as tax withheld.

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 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 nontaxable distributions as capital gains, even though this

form shows them as nontaxable. See Pub. 550, Investment Income

and Expenses.

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. See the Schedule D (Form 1040) instructions.

Box 6. Shows the foreign tax 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 2004 General Instructions

for Forms 1099, 1098, 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 a distribution from 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.
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 (optional)

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

2004 General

Instructions

for Forms

1099, 1098,

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

$ $

Nontaxable distributions

Form 1099-DIV

$

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

$

$

4 Federal income tax withheld

$

$

2004
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 2004 General

Instructions for Forms 1099, 1098, 5498, and W-2G

and the 2004 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, call

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

Due dates. Furnish Copy B of this form to the

recipient by January 31, 2005.

File Copy A of this form with the IRS by 

February 28, 2005. If you file electronically, the due

date is March 31, 2005.

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, or 5498 that you print from the IRS

website.