Form 1099-Cap - Changes In Corporate Control And Capital Structure - 2017 Page 4
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1
2
3
4
5VOID
CORRECTED
Changes in
CORPORATION'S name, street address, city or town, state or province,
1 Date of sale or exchange
OMB No. 1545-1814
country, ZIP or foreign postal code, and telephone no.
2017
Corporate
Control and
2 Aggregate amount rec'd*
Capital Structure
$
1099-CAP
Form
3 No. of shares exchanged
4 Classes of stock exchanged
Copy C
For Corporation
CORPORATION'S federal identification no. SHAREHOLDER'S identification no.
For Paperwork
SHAREHOLDER'S name
Reduction Act
Notice, see the
2017 General
Instructions for
Street address (including apt. no.)
Certain Information
5
Returns.
City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)
* The shareholder cannot claim a loss based on the
amount in box 2.
1099-CAP
Form
Department of the Treasury - Internal Revenue Service
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Parent category: Financial