Form 1099-Cap - Changes In Corporate Control And Capital Structure - 2012 Page 3
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1
2
3
4
5
6CORRECTED (if checked)
Changes in
1 Date of sale or exchange
OMB No. 1545-1814
CORPORATION’S name, street address, city, state, ZIP code, and telephone no.
2012
Corporate
Control and
2 Aggregate amount rec'd*
Capital Structure
$
1099-CAP
Form
3 No. of shares exchanged
4 Classes of stock exchanged
Copy B
For Shareholder
CORPORATION’S federal identification no.
SHAREHOLDER’S identification no.
This is important tax
information and is being
furnished to the Internal
SHAREHOLDER’S name
Revenue Service. If you
are required to file a
return, a negligence
Street address (including apt. no.)
penalty or other
sanction may be
5
imposed on you if
City, state, and ZIP code
taxable income results
from this transaction
and the IRS determines
Account number (see instructions)
that it has not been
* You cannot claim a loss based on the amount in box 2.
reported.
1099-CAP
(keep for your records)
Form
Department of the Treasury - Internal Revenue Service
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