1099-DIV Dividends and Distributions

Attention:
This form is provided for informational purposes only. Copy A appears in red, similar to the
official IRS form. Do not file copy A downloaded from this website. The official printed
version of this IRS form is scannable, but the online version of it, printed from this website, is
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current General Instructions for Certain Information Returns for more information about
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printing these tax forms.

9191

VOID

CORRECTED

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

1a Total ordinary dividends

OMB No. 1545-0110

2011

$
1b Qualified dividends

$

PAYER’S federal identification
number

RECIPIENT’S identification
number

RECIPIENT’S name

Form

1099-DIV

2a Total capital gain distr.

2b Unrecap. Sec. 1250 gain

$

$

2c Section 1202 gain

2d Collectibles (28%) gain

$
4 Federal income tax withheld

$
5 Investment expenses

$
Street address (including apt. no.)

6 Foreign tax paid

City, state, and ZIP code

8 Cash liquidation distributions

7 Foreign country or U.S. possession

9 Noncash liquidation distributions

$

$

$

Account number (see instructions)

Form 1099-DIV

2nd TIN not.

Cat. No. 14415N

Do Not Cut or Separate Forms on This Page

—

Copy A
For
Internal Revenue
Service Center
File with Form 1096.

$
3 Nondividend distributions

$

Dividends and
Distributions

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2011 General
Instructions for
Certain
Information
Returns.

Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page

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

1a Total ordinary dividends

OMB No. 1545-0110

2011

$
1b Qualified dividends

$

PAYER’S federal identification
number

RECIPIENT’S name

RECIPIENT’S identification
number

Form

Dividends and
Distributions

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

City, state, and ZIP code

8 Cash liquidation distributions

9 Noncash liquidation distributions

$

$

$

Account number (see instructions)

Form 1099-DIV

(keep for your records)

Copy B
For Recipient

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

Instructions for Recipient
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
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 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. A payer must backup withhold on certain
payments 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.
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 2011 General
Instructions for Certain Information Returns.

VOID

CORRECTED

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

1a Total ordinary dividends

OMB No. 1545-0110

2011

$
1b Qualified dividends

$

PAYER’S federal identification
number

RECIPIENT’S identification
number

RECIPIENT’S name

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

$

Dividends and
Distributions

$
5 Investment expenses

$
Street address (including apt. no.)

6 Foreign tax paid

7 Foreign country or U.S. possession

City, state, and ZIP code

8 Cash liquidation distributions

9 Noncash liquidation distributions

$

$

$

Account number (see instructions)

Form 1099-DIV

2nd TIN not.

Copy C
For Payer

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2011 General
Instructions for
Certain
Information
Returns.

Department of the Treasury - Internal Revenue Service

Instructions for Payer
General and specific form instructions are provided as
separate products. The products you should use to
complete Form 1099-DIV are the 2011 General
Instructions for Certain Information Returns and the
2011 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 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,
1097, 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, 2012.
File Copy A of this form with the IRS by February 28,
2012. If you file electronically, the due date is
April 2, 2012. To file electronically, you must have

software that generates a file according to the
specifications in Pub. 1220, Specifications for Filing
Forms 1097, 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.