Form 1099-CAP Changes in Corporate Control and Capital Structure

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Page 1 of 6 of Form 1099-CAP (page 2 is blank)

Action

2

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

Date

VOID

Revised proofs
requested

CORRECTED

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

1 Date of sale or exchange

OMB No. 1545-1814

2 Aggregate amount rec’d*

2010
1099-CAP

Changes in
Corporate
Control and
Capital Structure

$

Form

3 No. of shares exchanged

4 Classes of stock exchanged

f
o
s
a
9
t
0
f
0
a
2
r
/
D /13
7
0

CORPORATION’S federal identification no.

Signature

O.K. to print
Responsible
scan organization

Separation 1 for page 1 of Form 1099-CAP (2000). Prints in
Red (J-6983) Ink.
Separation 2 for page 1 of Form 1099-C (2000). Prints in Black Ink.

7373

Date

O.K. to print
T:FP:F

Copy A

SHAREHOLDER’S identification no.

For
Internal Revenue
Service Center
File with Form 1096.
For Paperwork
Reduction Act
Notice, see the
2010 General
Instructions for
Certain Information
Returns.

SHAREHOLDER’S name

Street address (including apt. no.)

5

City, state, and ZIP code

* The shareholder cannot claim a loss based on the

Account number (see instructions)

amount in box 2.

Form

1099-CAP

Cat. No. 35115M

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Department of the Treasury - Internal Revenue Service

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