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Form
1099-DIV
20
13
Dividends and
Distributions
Copy B
For Recipient
Department of the Treasury - Internal Revenue Service
This is important tax
information and is
being furnished to
the Internal Revenue
Service. If you are
required to file a
return, a negligence
penalty or other
sanction may be
imposed on you if
this income is taxable
and the IRS
determines that it has
not been reported.
OMB No. 1545-0110
CORRECTED (if checked)
PAYER’S federal identification number
RECIPIENT’S identification number
RECIPIENT’S name
Street address (including apt. no.)
City or town, province or state, country, and ZIP or foreign postal code
Account number (see instructions)
1a
Total ordinary dividends
$
1b
Qualified dividends
$
2a
Total capital gain distr.
$
2b
Unrecap. Sec. 1250 gain
$
2c
Section 1202 gain
$
2d
Collectibles (28%) gain
$
3
Nondividend distributions
$
4
Federal income tax withheld
$
5
Investment expenses
$
6
Foreign tax paid
$
7
Foreign country or U.S. possession
8
Cash liquidation distributions
$
9
Noncash liquidation distributions
$
10
Exempt-interest dividends
$
11
Specified private activity
bond interest dividends
$
12
State
13
State identification no.
14
State tax withheld
$
$
Form
1099-DIV
(keep for your records)
www.irs.gov/form1099div
City
State ZIP Code
Payer’s Name
PAYER’S INFORMATION
Street address (including apt. no.)
Telephone no.
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