1099-DIV Dividends and Distributions

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Page 1 of 6 of Form 1099-DIV (PAGE 2 IS BLANK)

4

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requested

Separation 1 for page 1 of Form 1099-DIV. Prints in
Red (J-6983) Ink.
Separation 2 for page 1 of Form 1099-DIV. Prints in Black Ink.

9191

VOID

CORRECTED
1a Total ordinary dividends

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

OMB No. 1545-0110

2010

$
1b Qualified dividends

$

PAYER’S federal identification
number

RECIPIENT’S identification
number

RECIPIENT’S name

Form

2b Unrecap. Sec. 1250 gain

$

$

2c Section 1202 gain

2d Collectibles (28%) gain

$

$

3

Nondividend distributions

Foreign tax paid

7

Foreign country or
U.S. possession

Cash liquidation
distributions

9 Noncash liquidation
distributions

$
City, state, and ZIP code

8

$

$

2nd TIN not. 10a Tax credit bond credits

For
Internal Revenue
Service Center

4 Federal income tax withheld

$
$

6

Copy A

File with Form 1096.

5 Investment expenses

Street address (including apt. no.)

Dividends and
Distributions

1099-DIV

2a Total capital gain distr.

$

Account number (see instructions)

Signature

O.K. to print
Responsible
scan organization

The type and rule above prints on all proofs including departmental
reproduction proofs. MUST be removed before printing.

Date

Date

O.K. to print
T:FP:F

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2010 General
Instructions for
Certain
Information
Returns

10b Code

$

Form

1099-DIV

Cat. No. 14415N

Department of the Treasury - Internal Revenue Service

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Page 3 of 6 of Form 1099-DIV

4

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

CORRECTED (if checked)
PAYER’S name, street address, city, state, ZIP code, and telephone no.

1a Total ordinary dividends

OMB No. 1545-0110

2010

$
1b Qualified dividends

$

PAYER’S federal identification
number

RECIPIENT’S name

RECIPIENT’S identification
number

Form

1099-DIV

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

$
Street address (including apt. no.)

6

Foreign tax paid

7

Foreign country or
U.S. possession

Cash liquidation
distributions

9 Noncash liquidation
distributions

$
City, state, and ZIP code

8

$
Account number (see instructions)

10a Tax credit bond credits

$

Form

1099-DIV

(keep for your records)

Copy B
For Recipient

$

$

Dividends and
Distributions

$
10b Code

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.

Department of the Treasury - Internal Revenue Service

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Page 4 of 6 Form 1099-DIV

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

Instructions for Recipients
Account number. May show an account or other unique number the payer
assigned to distinguish your account.
Box 1a. Shows total ordinary dividends that are taxable. Include this amount
on line 9a of Form 1040 or 1040A. Also, report it on Schedule B (Form 1040)
or Schedule 1 (Form 1040A), if required.
The amount shown may be dividends a corporation paid directly to you as a
participant (or beneficiary of a participant) in an employee stock ownership
plan (ESOP). Report it as a dividend on your Form 1040/1040A but treat it as a
plan distribution, not as investment income, for any other purpose.
Box 1b. Shows the portion of the amount in box 1a that may be eligible for
the 15% or zero capital gains rates. See the Form 1040/1040A instructions for
how to determine this amount. Report the eligible amount on line 9b, Form
1040 or 1040A.
Box 2a. Shows total capital gain distributions from a regulated investment
company or real estate investment trust. Report the amounts shown in box 2a
on Schedule D (Form 1040), line 13. But, if no amount is shown in boxes
2c–2d and your only capital gains and losses are capital gain distributions, you
may be able to report the amounts shown in box 2a on line 13 of Form 1040
(line 10 of Form 1040A) rather than Schedule D. See the Form 1040/1040A
instructions.
Box 2b. Shows the portion of the amount in box 2a that is unrecaptured
section 1250 gain from certain depreciable real property. Report this amount
on the Unrecaptured Section 1250 Gain Worksheet–Line 19 in the Schedule D
instructions (Form 1040).
Box 2c. Shows the portion of the amount in box 2a that is section 1202 gain
from certain small business stock that may be subject to a 50% exclusion and
certain empowerment zone business stock that may be subject to a 60%
exclusion. See the Schedule D (Form 1040) instructions.
Box 2d. Shows 28% rate gain from sales or exchanges of collectibles. If
required, use this amount when completing the 28% Rate Gain
Worksheet–Line 18 in the instructions for Schedule D (Form 1040).

Box 3. Shows the part of the distribution that is nontaxable because it is a
return of your cost (or other basis). You must reduce your cost (or other basis)
by this amount for figuring gain or loss when you sell your stock. But if you get
back all your cost (or other basis), report future distributions as capital gains.
See Pub. 550, Investment Income and Expenses.
Box 4. Shows backup withholding. For example, a payer must backup
withhold on certain payments at a 28% rate if you did not give your taxpayer
identification number to the payer. See Form W-9, Request for Taxpayer
Identification Number and Certification, for information on backup withholding.
Include this amount on your income tax return as tax withheld.
Box 5. Shows your share of expenses of a nonpublicly offered regulated
investment company, generally a nonpublicly offered mutual fund. If you file
Form 1040, you may deduct these expenses on the “Other expenses” line on
Schedule A (Form 1040) subject to the 2% limit. This amount is included in
box 1a.
Box 6. Shows the foreign tax that you may be able to claim as a deduction or
a credit on Form 1040. See the Form 1040 instructions.
Box 7. This box should be left blank if a regulated investment company
reported the foreign tax shown in box 6.
Boxes 8 and 9. Shows cash and noncash liquidation distributions.
Box 10a. Shows your share of credits from tax credit bonds distributed to you
by a regulated investment company or a real estate investment trust.
Box 10b. The codes for tax credit bond types are: BA—Build America bond;
CR—Clean renewable energy bond; NC—New clean renewable energy bond;
QE—Qualified energy conservation bond; QF—Qualified forestry conservation
bond; QS—Qualified school construction bond; and QZ—Qualified zone
academy bond.
Nominees. If this form includes amounts belonging to another person, you are
considered a nominee recipient. You must file Form 1099-DIV with the IRS for
each of the other owners to show their share of the income, and you must
furnish a Form 1099-DIV to each. A husband or wife is not required to file a
nominee return to show amounts owned by the other. See the 2010 General
Instructions for Certain Information Returns.

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Page 5 of 6 of Form 1099-DIV

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

VOID

CORRECTED

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

1a Total ordinary dividends

OMB No. 1545-0110

2010

$
1b Qualified dividends

$

PAYER’S federal identification
number

RECIPIENT’S identification
number

Form

1099-DIV

2a Total capital gain distr.

2b Unrecap. Sec. 1250 gain

$

$

2c Section 1202 gain

2d Collectibles (28%) gain

$
RECIPIENT’S name

3

For Payer

4 Federal income tax withheld

$
5 Investment expenses

$
6

Foreign tax paid

7

Foreign country or
U.S. possession

Cash liquidation
distributions

9 Noncash liquidation
distributions

$
City, state, and ZIP code

8

$
Account number (see instructions)

Copy C

$
Nondividend distributions

$

Street address (including apt. no.)

Dividends and
Distributions

2nd TIN not. 10a Tax credit bond credits

$

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2010 General
Instructions for
Certain
Information
Returns.

10b Code

$

Form

1099-DIV

Department of the Treasury - Internal Revenue Service

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Page 6 of 6 Form 1099-DIV

4

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

Instructions for Payers
General and specific form instructions are provided as
separate products. The products you should use to
complete Form 1099-DIV are the 2010 General
Instructions for Certain Information Returns and the
2010 Instructions for Form 1099-DIV. A chart in the
general instructions gives a quick guide to which form
must be filed to report a particular payment. To order
these instructions and additional forms, visit the IRS
website at www.irs.gov or call 1-800-TAX-FORM
(1-800-829-3676).
Caution: Because paper forms are scanned during
processing, you cannot file with the IRS Forms 1096,
1098, 1099, 3921, 3922, or 5498 that you print from
the IRS website.
Due dates. Furnish Copy B of this form to the
recipient by January 31, 2011.
File Copy A of this form with the IRS by
February 28, 2011. If you file electronically, the due
date is March 31, 2011. To file electronically, you must

have software that generates a file according to the
specifications in Pub. 1220, Specifications for Filing
Forms 1098, 1099, 3921, 3922, 5498, 8935, and W-2G
Electronically. IRS does not provide a fill-in form
option.
Foreign dividend recipient. If the recipient of the
dividend is a nonresident alien, you may have to
withhold federal income tax and file Form 1042-S,
Foreign Person’s U.S. Source Income Subject to
Withholding. See the Instructions for Form 1042-S and
Pub. 515, Withholding of Tax on Nonresident Aliens
and Foreign Entities.
Need help? If you have questions about reporting on
Form 1099-DIV, call the information reporting customer
service site toll free at 1-866-455-7438 or
304-263-8700 (not toll free). For TTY/TDD equipment,
call 304-579-4827 (not toll free). The hours of operation
are Monday through Friday from 8:30 a.m. to 4:30
p.m., Eastern time.

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