Dividend Statement Form

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Dividend Statement
NAME: _____________________________________________________________________
DUE DATE: _________________________________________________________________
ACCOUNT NUMBER: __________________________________________________________
SECURITY CODE: ____________________________________________________________
SECURITY IDENTIFICATION: ___________________________________________________
QUANTITY: _________________________________________________________________
GROSS AMOUNT: ____________________________________________________________
TAX %: ____________________________________________________________________
AMOUNT TAXES: _____________________________________________________________
AMOUNT AFTER TAXES: _______________________________________________________
Name of customer:
________________________________________________________
___________________________________
______________________________________
Authorised Signatory
Name
______________________________________
Title
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