Form 1099-DIV 

2016

Cat. No. 14415N 

Dividends and 

Distributions 

Copy A

For 

Internal Revenue 

Service Center 

Department of the Treasury - Internal Revenue Service

File with Form 1096.

OMB No. 1545-0110 

For Privacy Act 

and Paperwork 

Reduction Act 

Notice, see the 

2016 General 

Instructions for 

Certain 

Information 

Returns. 

9191 VOID CORRECTED

PAYER’S name, street address, city or town, state or province, country, ZIP 

or foreign postal code, and telephone no. 

PAYER’S federal identification number RECIPIENT’S identification number 

RECIPIENT’S name 

Street address (including apt. no.) 

City or town, state or province, country, and ZIP or foreign postal code

FATCA filing 

requirement

Account number (see instructions) 2nd TIN not. 

1a Total ordinary dividends 

$ 

1b Qualified dividends

$ 

2a Total capital gain distr.

$ 

2b Unrecap. Sec. 1250 gain 

$ 

2c Section 1202 gain 

$ 

2d Collectibles (28%) gain 

$ 

3 Nondividend distributions 

$ 

4 Federal income tax withheld 

$ 

5 Investment expenses 

$ 

6 Foreign tax paid 

$ 

7 Foreign country or U.S. possession 

8 Cash liquidation distributions 

$ 

9 Noncash liquidation distributions 

$ 

10 Exempt-interest dividends

$ 

11 Specified private activity 

bond interest dividends

$ 

12 State 13 State identification no. 14 State tax withheld

$ 

$ 

Form 1099-DIV www.irs.gov/form1099div

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

Form 1099-DIV 

2016 Dividends and 

Distributions 

Copy 1

For State Tax 

Department 

Department of the Treasury - Internal Revenue Service

OMB No. 1545-0110 

VOID CORRECTED

PAYER’S name, street address, city or town, state or province, country, ZIP 

or foreign postal code, and telephone no. 

PAYER’S federal identification number RECIPIENT’S identification number 

RECIPIENT’S name 

Street address (including apt. no.) 

City or town, state or province, country, and ZIP or foreign postal code

FATCA filing 

requirement

Account number (see instructions) 

1a Total ordinary dividends 

$ 

1b Qualified dividends

$ 

2a Total capital gain distr.

$ 

2b Unrecap. Sec. 1250 gain 

$ 

2c Section 1202 gain 

$ 

2d Collectibles (28%) gain 

$ 

3 Nondividend distributions 

$ 

4 Federal income tax withheld 

$ 

5 Investment expenses 

$ 

6 Foreign tax paid 

$ 

7 Foreign country or U.S. possession 

8 Cash liquidation distributions 

$ 

9 Noncash liquidation distributions 

$ 

10 Exempt-interest dividends

$ 

11 Specified private activity 

bond interest dividends

$ 

12 State 13 State identification no. 14 State tax withheld

$ 

$ 

Form 1099-DIV www.irs.gov/form1099div
 

Form 1099-DIV 

2016 Dividends and 

Distributions 

Copy B 

For Recipient 

Department of the Treasury - Internal Revenue Service

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. 

OMB No. 1545-0110 

CORRECTED (if checked)

PAYER’S name, street address, city or town, state or province, country, ZIP 

or foreign postal code, and telephone no. 

PAYER’S federal identification number RECIPIENT’S identification number 

RECIPIENT’S name 

Street address (including apt. no.) 

City or town, state or province, country, and ZIP or foreign postal code

FATCA filing 

requirement

Account number (see instructions) 

1a Total ordinary dividends 

$ 

1b Qualified dividends

$ 

2a Total capital gain distr.

$ 

2b Unrecap. Sec. 1250 gain 

$ 

2c Section 1202 gain 

$ 

2d Collectibles (28%) gain 

$ 

3 Nondividend distributions 

$ 

4 Federal income tax withheld 

$ 

5 Investment expenses 

$ 

6 Foreign tax paid 

$ 

7 Foreign country or U.S. possession 

8 Cash liquidation distributions 

$ 

9 Noncash liquidation distributions 

$ 

10 Exempt-interest dividends

$ 

11 Specified private activity 

bond interest dividends

$ 

12 State 13 State identification no. 14 State tax withheld

$ 

$ 

Form 1099-DIV (keep for your records) www.irs.gov/form1099div
Instructions for Recipient 

Recipient's identification number. For your protection, this form may show 

only the last four digits of your social security number (SSN), individual taxpayer 

identification number (ITIN), adoption taxpayer identification number (ATIN), or 

employer identification number (EIN). However, the issuer has reported your 

complete identification number to the IRS.

FATCA filing requirement. If the FATCA filing requirement box is checked, the 

payer is reporting on this Form 1099 to satisfy its chapter 4 account reporting 

requirement. You also may have a filing requirement. See the Instructions for 

Form 8938.

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

assigned to distinguish your account. 

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 (1040A or 1040), if 

required. 

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

reduced capital gains rates. See Form 1040/1040A instructions for how to 

determine this amount. Report the eligible amount on line 9b, Form 1040 or 

1040A. 

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 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 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 an exclusion. See the 

Schedule D (Form 1040) instructions. 

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). 

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.

Box 4. Shows backup withholding. A payer must backup withhold on certain 

payments 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 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 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. 

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

the foreign tax shown in box 6. 

Boxes 8 and 9. Shows cash and noncash liquidation distributions. 

Box 10. Shows exempt-interest dividends from a mutual fund or other regulated 

investment company paid to you during the calendar year. Include this amount 

on line 8b of Form 1040 or 1040A as tax-exempt interest. This amount may be 

subject to backup withholding. See box 4.

Box 11. Shows exempt-interest dividends subject to the alternative minimum 

tax. This amount is included in box 10. See the Instructions for Form 6251.

Boxes 12–14. State income tax withheld reporting boxes.

Nominees. If this form includes amounts belonging to another person, you are 

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

Form 1096) 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 spouse is not 

required to file a nominee return to show amounts owned by the other spouse. 

See the 2016 General Instructions for Certain Information Returns. 

Future developments. For the latest information about the developments 

related to Form 1099-DIV and its instructions, such as legislation enacted after 

they were published, go to www.irs.gov/form1099div.
 

Form 1099-DIV 

2016 Dividends and 

Distributions 

Copy 2

To be filed with 

recipient's state 

income tax return, 

when required.

Department of the Treasury - Internal Revenue Service

OMB No. 1545-0110 

VOID CORRECTED

PAYER’S name, street address, city or town, state or province, country, ZIP 

or foreign postal code, and telephone no. 

PAYER’S federal identification number RECIPIENT’S identification number 

RECIPIENT’S name 

Street address (including apt. no.) 

City or town, state or province, country, and ZIP or foreign postal code

FATCA filing 

requirement

Account number (see instructions) 

1a Total ordinary dividends 

$ 

1b Qualified dividends

$ 

2a Total capital gain distr.

$ 

2b Unrecap. Sec. 1250 gain 

$ 

2c Section 1202 gain 

$ 

2d Collectibles (28%) gain 

$ 

3 Nondividend distributions 

$ 

4 Federal income tax withheld 

$ 

5 Investment expenses 

$ 

6 Foreign tax paid 

$ 

7 Foreign country or U.S. possession 

8 Cash liquidation distributions 

$ 

9 Noncash liquidation distributions 

$ 

10 Exempt-interest dividends

$ 

11 Specified private activity 

bond interest dividends

$ 

12 State 13 State identification no. 14 State tax withheld

$ 

$ 

Form 1099-DIV www.irs.gov/form1099div
 

Form 1099-DIV 

2016 Dividends and 

Distributions 

Copy C

For Payer

Department of the Treasury - Internal Revenue Service

OMB No. 1545-0110 

For Privacy Act 

and Paperwork 

Reduction Act 

Notice, see the 

2016 General 

Instructions for 

Certain 

Information 

Returns.

VOID CORRECTED

PAYER’S name, street address, city or town, state or province, country, ZIP 

or foreign postal code, and telephone no. 

PAYER’S federal identification number RECIPIENT’S identification number 

RECIPIENT’S name 

Street address (including apt. no.) 

City or town, state or province, country, and ZIP or foreign postal code

FATCA filing 

requirement

Account number (see instructions) 2nd TIN not. 

1a Total ordinary dividends 

$ 

1b Qualified dividends

$ 

2a Total capital gain distr.

$ 

2b Unrecap. Sec. 1250 gain 

$ 

2c Section 1202 gain 

$ 

2d Collectibles (28%) gain 

$ 

3 Nondividend distributions 

$ 

4 Federal income tax withheld 

$ 

5 Investment expenses 

$ 

6 Foreign tax paid 

$ 

7 Foreign country or U.S. possession 

8 Cash liquidation distributions 

$ 

9 Noncash liquidation distributions 

$ 

10 Exempt-interest dividends

$ 

11 Specified private activity 

bond interest dividends

$ 

12 State 13 State identification no. 14 State tax withheld

$ 

$ 

Form 1099-DIV www.irs.gov/form1099div
Instructions for Payer 

To complete Form 1099-DIV, use:

• the 2016 General Instructions for Certain Information 

Returns, and

• the 2016 Instructions for Form 1099-DIV.

To order these instructions and additional forms, go 

to www.irs.gov/form1099div. 

Caution: Because paper forms are scanned during 

processing, you cannot file Forms 1096, 1097, 1098, 

1099, 3921, 3922, or 5498 that you print from the IRS 

website. 

Due dates. Furnish Copy B of this form to the recipient 

by January 31, 2017. 

File Copy A of this form with the IRS by February 28, 

2017. If you file electronically, the due date is 

March 31, 2017. To file electronically, you must have 

software that generates a file according to the 

specifications in Pub. 1220. The IRS does not provide a 

fill-in form option. 

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. See 

the Instructions for Form 1042-S and Pub. 515. 

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). Persons with a hearing or speech 

disability with access to TTY/TDD equipment can call 

304-579-4827 (not toll free).