Form 1099-Cap - Changes In Corporate Control And Capital Structure - 2003 Page 2
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1
2
3
47373
VOID
CORRECTED
Changes in
CORPORATION’S/BROKER’S name, street address, city, state, ZIP code, and
1
Date of sale or exchange
OMB No. 1545-1814
telephone no.
Corporate
2003
Control and
2
CUSIP No.
Capital Structure
1099-CAP
Form
3
Cash received
Reported
Gross proceeds
to IRS
$
Gross proceeds less commissions and option premiums
CORPORATION’S/BROKER’S
SHAREHOLDER’S identification no.
4
Federal income tax withheld
5
No. of shares exchanged
Copy A
Federal identification no.
$
For
6
Internal Revenue
7
Classes of stock exchanged
Service Center
SHAREHOLDER’S name
File with Form 1096.
8
FMV of stock received
9
FMV of other property received
For Privacy Act
$
$
Street address (including apt. no.)
and Paperwork
Reduction Act
10 Description
Notice, see the
City, state, and ZIP code
2003 General
Instructions for
Forms 1099, 1098,
Account number (optional)
Check if filed
2nd TIN not.
Check the box if shareholder cannot take a loss on their
5498, and W-2G.
by broker
tax return
1099-CAP
Form
Cat. No. 35115M
Department of the Treasury - Internal Revenue Service
Do Not Cut or Separate Forms on This Page
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Do Not Cut or Separate Forms on This Page
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