EFTA01222593.pdf

CORRECTED if check PAYER'S name. street address. city or town. state or province, country. ZIP to Tots ordinary dividends OMB No. 1545-0110 or foreign postal code. and telephone no. $ Dividends and lb Qualified dividends 2017 Distributions $ Form 1099-DIV 2a Total capital gain distr. 2b Unrecap. Sec. 1250 gain Copy B For Recipient PAYER'S federal identification number RECIPIENT'S identification number 2c Section 1202 gain 2d Collectibles (28%) gain $ RECIPIENT'S name 3 NondMdend distributions 4 Federal mome tax withheld This is important tax $ information and is 5 Investment expenses being furnished to the Internal Revenue Street address fincludirg apt. no.) $ Service. If you are 6 Foreign tax paid 7 Foreign coutry or U.S. possession required to file a return. a negligence penalty or other City or town. state or province. country. and ZIP or foreign postal code $ sanction may be imposed on you if 8 Cash licsidation distributions 9 Noncash irsidaticn dsubutions this income is taxable $ $ and the IRS determines that it has FATCA filng 10 Exempt-interest dividends 11 Specified private activity not been reported. requirement bond interest dwidends 0 $ $ Account number (see instructions) 12 State 13 suilegeninceionno 14 State tax withheld $ I Form 1099-DIV (keep for your records) www.iragovfican1099div Department of the Treason - Internal Revenue Service EFTA01222593