Form 1099-Div - Dividends And Distributions

Form 1099-Div - Dividends And Distributions - 2012 Page 2

9191

VOID

CORRECTED

PAYER’S name, street address, city, state, ZIP code, and telephone no.

1a Total ordinary dividends

OMB No. 1545-0110

Dividends and

2012

Distributions

1b Qualified dividends

1099-DIV

Form

Copy A

2a Total capital gain distr.

2b Unrecap. Sec. 1250 gain

For

Internal Revenue

PAYER’S federal identification

RECIPIENT’S identification

2c Section 1202 gain

2d Collectibles (28%) gain

Service Center

number

File with Form 1096.

RECIPIENT’S name

3 Nondividend distributions

4 Federal income tax withheld

For Privacy Act

and Paperwork

5 Investment expenses

Reduction Act

Notice, see the

Street address (including apt. no.)

6 Foreign tax paid

7 Foreign country or U.S. possession

2012 General

Instructions for

Certain

City, state, and ZIP code

Information

8 Cash liquidation distributions

9 Noncash liquidation distributions

Returns.

10 Exempt-interest dividends

11 Specified private activity

Account number (see instructions)

2nd TIN not.

bond interest dividends

12 State

13 State identification

14 State tax withheld

no.

1099-DIV

Form

Cat. No. 14415N

Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page

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Do Not Cut or Separate Forms on This Page

Form 1099-Div - Dividends And Distributions - 2012 Page 2

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