Tax return

VOID CORRECTED9191 PAYER'S name, street address, city or town, state or province, country, 1a Total ordinary dividends OMB No. 1545-0110

ZIP or foreign postal code, and telephone no.

MICKEY'S BURGER PALACE $ 800.00 1 MAIN STREET 1b Qualified dividends 2016 Dividends and ROCKVILLE, MD 20850 Distributions

$ Form 1099-DIV

2a Total capital gain distr. 2b Unrecap. Sec. 1250 gain Copy A $ $ For

PAYER’S federal identification number RECIPIENT'S identification number 2c Section 1202 gain 2d Collectibles (28%) gain Internal Revenue

Service Center

52-5555555 111-22-3333 $ $ File with Form 1096. RECIPIENT'S name 3 Nondividend distributions 4 Federal income tax withheld

$ $ For Privacy Act MICHAEL M MCDONALD 5 Investment expenses and Paperwork Street address (including apt. no.) $ Reduction Act

6 Foreign tax paid 7 Foreign country or U.S. possession Notice, see the 2 WEST JEFFERSON STREET 2016 General2016 General City or town, state or province, country, and ZIP or foreign postal code $ Instructions for

8 Cash liquidation distributions 9 Noncash liquidation distributions Certain

SILVER SPRING, MD 20904 $ $ Information 10 Exempt-interest dividends 11 Specified private activity Returns. FATCA filing

requirement bond interest dividends

$ $ Account number (see instructions) 2nd TIN not. 12 State 13 State identification no. 14 State tax withheld

$

$

Form 1099-DIV www.irs.gov/form1099div Department of the Treasury - Internal Revenue Service

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VOID CORRECTED9191 PAYER'S name, street address, city or town, state or province, country, 1a Total ordinary dividends OMB No. 1545-0110

ZIP or foreign postal code, and telephone no.

$ 1b Qualified dividends 2016 Dividends and

Distributions $ Form 1099-DIV 2a Total capital gain distr. 2b Unrecap. Sec. 1250 gain Copy A $ $ For

PAYER’S federal identification number RECIPIENT'S identification number 2c Section 1202 gain 2d Collectibles (28%) gain Internal Revenue

Service Center

$ $ File with Form 1096.

RECIPIENT'S name 3 Nondividend distributions 4 Federal income tax withheld

$ $ For Privacy Act 5 Investment expenses and Paperwork

Street address (including apt. no.) $ Reduction Act 6 Foreign tax paid 7 Foreign country or U.S. possession Notice, see the

2016 General2016 General City or town, state or province, country, and ZIP or foreign postal code $ Instructions for

8 Cash liquidation distributions 9 Noncash liquidation distributions Certain

$ $ Information 10 Exempt-interest dividends 11 Specified private activity Returns. FATCA filing

requirement bond interest dividends

$ $ Account number (see instructions) 2nd TIN not. 12 State 13 State identification no. 14 State tax withheld

$

$

Form 1099-DIV www.irs.gov/form1099div Department of the Treasury - Internal Revenue Service