Form 1099-Div - Dividends And Distributions

Form 1099-Div - Dividends And Distributions - 2017 Page 3

VOID

CORRECTED

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

2017

Distributions

1b Qualified dividends

1099-DIV

Form

Copy 1

2a Total capital gain distr.

2b Unrecap. Sec. 1250 gain

For State Tax

PAYER’S federal identification number RECIPIENT’S identification number

Department

2c Section 1202 gain

2d Collectibles (28%) gain

RECIPIENT’S name

3 Nondividend distributions

4 Federal income tax withheld

5 Investment expenses

Street address (including apt. no.)

6 Foreign tax paid

7 Foreign country or U.S. possession

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

8 Cash liquidation distributions

9 Noncash liquidation distributions

10 Exempt-interest dividends

11 Specified private activity

FATCA filing

requirement

bond interest dividends

Account number (see instructions)

12 State

14 State tax withheld

State identification no.

1099-DIV

Form

Department of the Treasury - Internal Revenue Service

Form 1099-Div - Dividends And Distributions - 2017 Page 3