Form  1099-DIV 

2013Dividends 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

CityState       ZIP Code

Payer’s NamePAYER’S INFORMATION

Street address (including apt. no.)

Telephone no.

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