Form 1099-Div - Dividends And Distributions - 2014 Page 7
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8VOID
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
2014
$
Distributions
1b Qualified dividends
$
1099-DIV
Form
Copy C
2a Total capital gain distr.
2b Unrecap. Sec. 1250 gain
$
$
For Payer
PAYER’S federal identification number RECIPIENT’S identification number
2c Section 1202 gain
2d Collectibles (28%) gain
$
$
RECIPIENT’S name
3 Nondividend distributions
4 Federal income tax withheld
For Privacy Act
$
$
and Paperwork
5 Investment expenses
Reduction Act
$
Street address (including apt. no.)
Notice, see the
6 Foreign tax paid
7 Foreign country or U.S. possession
2014 General
Instructions for
$
City or town, state or province, country, and ZIP or foreign postal code
Certain
Information
8 Cash liquidation distributions
9 Noncash liquidation distributions
Returns.
$
$
10 Exempt-interest dividends
11 Specified private activity
bond interest dividends
$
$
Account number (see instructions)
2nd TIN not.
12 State
13
14 State tax withheld
State identification no.
$
$
1099-DIV
Form
Department of the Treasury - Internal Revenue Service
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