SCHEDULE B
OMB No. 1545-0074
Interest and Ordinary Dividends
2012
(Form 1040A or 1040)
Attach to Form 1040A or 1040.
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Department of the Treasury
Attachment
Information about Schedule B (Form 1040A or 1040) and its instructions is at
08
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Internal Revenue Service (99)
Sequence No.
Name(s) shown on return
Your social security number
Part I
Amount
1
List name of payer. If any interest is from a seller-financed mortgage and the
buyer used the property as a personal residence, see instructions on back and list
Interest
this interest first. Also, show that buyer’s social security number and address
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(See instructions
on back and the
instructions for
Form 1040A, or
1
Form 1040,
line 8a.)
Note. If you
received a Form
1099-INT, Form
1099-OID, or
substitute
statement from
a brokerage firm,
list the firm’s
name as the
2
Add the amounts on line 1 .
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2
payer and enter
3
Excludable interest on series EE and I U.S. savings bonds issued after 1989.
the total interest
3
Attach Form 8815 .
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shown on that
form.
4
Subtract line 3 from line 2. Enter the result here and on Form 1040A, or Form
4
1040, line 8a
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Amount
Note. If line 4 is over $1,500, you must complete Part III.
Part II
5
List name of payer
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Ordinary
Dividends
(See instructions
on back and the
instructions for
Form 1040A, or
Form 1040,
5
line 9a.)
Note. If you
received a Form
1099-DIV or
substitute
statement from
a brokerage firm,
list the firm’s
name as the
payer and enter
the ordinary
6
Add the amounts on line 5. Enter the total here and on Form 1040A, or Form
dividends shown
1040, line 9a
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6
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on that form.
Note. If line 6 is over $1,500, you must complete Part III.
You must complete this part if you (a) had over $1,500 of taxable interest or ordinary dividends; (b) had a
Yes No
foreign account; or (c) received a distribution from, or were a grantor of, or a transferor to, a foreign trust.
7a At any time during 2012, did you have a financial interest in or signature authority over a financial
Part III
account (such as a bank account, securities account, or brokerage account) located in a foreign
Foreign
country? See instructions .
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Accounts
If “Yes,” are you required to file Form TD F 90-22.1 to report that financial interest or signature
and Trusts
authority? See Form TD F 90-22.1 and its instructions for filing requirements and exceptions to
those requirements .
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(See
instructions on
b
If you are required to file Form TD F 90-22.1, enter the name of the foreign country where the
back.)
financial account is located
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8
During 2012, did you receive a distribution from, or were you the grantor of, or transferor to, a
foreign trust? If “Yes,” you may have to file Form 3520. See instructions on back .
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Cat. No. 17146N
Schedule B (Form 1040A or 1040) 2012
For Paperwork Reduction Act Notice, see your tax return instructions.