Tax Return

Form 1099-DIV

2018 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 IRS. 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 name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.

PAYER’S TIN RECIPIENT’S TIN

RECIPIENT’S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

FATCA filing requirement

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 Section 199A dividends

$ 6 Investment expenses

$ 7 Foreign tax paid

$

8 Foreign country or U.S. possession

9 Cash liquidation distributions

$ 10 Noncash liquidation distributions

$ 11 Exempt-interest dividends

$

12 Specified private activity bond interest dividends

$ 13 State 14 State identification no. 15 State tax withheld

$ $

Form 1099-DIV (keep for your records) www.irs.gov/Form1099DIV