Form 1099-Div - Dividends And Distributions - 2016 Page 2
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1
2
3
4
5
6
7
8VOID
CORRECTED
9191
1a Total ordinary dividends
OMB No. 1545-0110
PAYER’S name, street address, city or town, state or province, country, ZIP
or foreign postal code, and telephone no.
Dividends and
2018
$
Distributions
1b Qualified dividends
$
1099-DIV
Form
Copy A
2a Total capital gain distr.
2b Unrecap. Sec. 1250 gain
$
$
For
Internal Revenue
PAYER’S TIN
RECIPIENT’S TIN
2c Section 1202 gain
2d Collectibles (28%) gain
Service Center
File with Form 1096.
$
$
RECIPIENT’S name
3
Nondividend distributions
4
Federal income tax withheld
For Privacy Act
$
$
and Paperwork
5
Investment expenses
Reduction Act
$
Street address (including apt. no.)
Notice, see the
6
Foreign tax paid
7
Foreign country or U.S. possession
2018 General
Instructions for
$
City or town, state or province, country, and ZIP or foreign postal code
Certain
Information
8
Cash liquidation distributions
9
Noncash liquidation distributions
Returns.
$
$
10 Exempt-interest dividends
11 Specified private activity
FATCA filing
requirement
bond interest dividends
$
$
Account number (see instructions)
2nd TIN not.
12 State
13
14 State tax withheld
State identification no.
$
$
1099-DIV
Form
Cat. No. 14415N
Department of the Treasury - Internal Revenue Service
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Do Not Cut or Separate Forms on This Page
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