Form 1099-CAP Changes in Corporate Control and Capital Structure

Attention:
Copy A of this form is provided for informational purposes only. Copy A appears in red,
similar to the official IRS form. The official printed version of Copy A of this IRS form is
scannable, but the online version of it, printed from this website, is not. Do not print and file
copy A downloaded from this website; a penalty may be imposed for filing with the IRS
information return forms that can’t be scanned. See part O in the current General
Instructions for Certain Information Returns, available at www.irs.gov/form1099, for more
information about penalties.
Please note that Copy B and other copies of this form, which appear in black, may be
downloaded and printed and used to satisfy the requirement to provide the information to
the recipient.
To order official IRS information returns, which include a scannable Copy A for filing with
the IRS and all other applicable copies of the form, visit www.IRS.gov/orderforms. Click on
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Information returns may also be filed electronically using the IRS Filing Information Returns
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forms.

7373

VOID

CORRECTED

CORPORATION'S name, street address, city or town, state or province,
country, ZIP or foreign postal code, and telephone no.

1 Date of sale or exchange
2 Aggregate amount rec'd*

$

OMB No. 1545-1814

2016

Form 1099-CAP

3 No. of shares exchanged

Changes in
Corporate
Control and
Capital Structure

4 Classes of stock exchanged

Copy A
CORPORATION'S federal identification no. SHAREHOLDER'S identification no.

For
Internal Revenue
Service Center

SHAREHOLDER'S name

Street address (including apt. no.)
5
City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)

* The shareholder cannot claim a loss based on the
amount in box 2.

File with Form 1096.
For Paperwork
Reduction Act
Notice, see the
2016 General
Instructions for
Certain Information
Returns.

1099-CAP
Cat. No. 35115M
www.irs.gov/form1099cap
Department of the Treasury - Internal Revenue Service
Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page

Form

CORRECTED (if checked)
CORPORATION'S name, street address, city or town, state or province,
country, ZIP or foreign postal code, and telephone no.

1 Date of sale or exchange
2 Aggregate amount rec'd*

$
3 No. of shares exchanged

OMB No. 1545-1814

2016

Changes in
Corporate
Control and
Capital Structure

Form 1099-CAP
4 Classes of stock exchanged

Copy B
For Shareholder

CORPORATION'S federal identification no. SHAREHOLDER'S identification no.
SHAREHOLDER'S name

Street address (including apt. no.)
5
City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)
Form

1099-CAP

(keep for your records)

* You cannot claim a loss based on the amount in box 2.
www.irs.gov/form1099cap

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
taxable income results
from this transaction
and the IRS determines
that it has not been
reported.

Department of the Treasury - Internal Revenue Service

Instructions for Shareholder
A corporation in which you own stock that has had a
change in control or a substantial change in capital
structure must send you this statement by January 31 of
the year following the calendar year of the change. You
have received this statement because the corporation
has reasonably determined that you may be required to
recognize gain from the receipt of cash, stock, or other
property that was exchanged for the corporation’s
stock. Report any gain from the exchange on Form
8949. However, you cannot claim a (loss) on Form 8949
as a result of this exchange. See Pub. 550, chapter 4,
for additional information.
Shareholder's identification number. For your
protection, this form may show only the last four digits
of your social security number (SSN), individual
taxpayer identification number (ITIN), adoption taxpayer
identification number (ATIN), or employer identification
number (EIN). However, the issuer has reported your
complete identification number to the IRS.

Account number. May show an account or other
unique number the payer corporation assigned to
distinguish your account.
Box 1. Shows the date the stock was exchanged for
cash, stock, or other property.
Box 2. Shows the aggregate amount of any cash and
the fair market value of any stock or other property
received by you in the exchange for the stock you held.
Box 3. Shows the number of shares of the corporation’s
stock that you held which were exchanged in the
transaction.
Box 4. Shows the class or classes of stock that were
exchanged.
Future developments. For the latest information about
developments related to Form 1099-CAP and its
instructions, such as legislation enacted after they were
published, go to www.irs.gov/form1099cap.

VOID

CORRECTED

CORPORATION'S name, street address, city or town, state or province,
country, ZIP or foreign postal code, and telephone no.

1 Date of sale or exchange
2 Aggregate amount rec'd*

$

OMB No. 1545-1814

2016

Form 1099-CAP

3 No. of shares exchanged

Changes in
Corporate
Control and
Capital Structure

4 Classes of stock exchanged

Copy C
For Corporation

CORPORATION'S federal identification no. SHAREHOLDER'S identification no.

For Paperwork
Reduction Act
Notice, see the
2016 General
Instructions for
Certain Information
Returns.

SHAREHOLDER'S name

Street address (including apt. no.)
5
City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)
Form

1099-CAP

* The shareholder cannot claim a loss based on the
amount in box 2.
www.irs.gov/form1099cap

Department of the Treasury - Internal Revenue Service

Instructions for Corporation
To complete Form 1099-CAP, use:
• the 2016 General Instructions for Certain Information
Returns, and
• the 2016 Instructions for Form 1099-CAP.
To order these instructions and additional forms, go
to www.irs.gov/form1099cap.
Caution: Because paper forms are scanned during
processing, you cannot file Forms 1096, 1097, 1098,
1099, 3921, 3922, or 5498 that you print from the IRS
website.
Due dates. Generally, furnish Copy B of this form to the
shareholder by January 31, 2017. However, if the
recipient is a clearing organization, furnish Copy B by
January 5, 2017.

File Copy A of this form with the IRS by February 28,
2017. If you file electronically, the due date is March 31,
2017. To file electronically, you must have software that
generates a file according to the specifications in Pub.
1220. The IRS does not provide a fill-in form option.
Need help? If you have questions about reporting on
Form 1099-CAP, call the information reporting customer
service site toll free at 1-866-455-7438 or 304-263-8700
(not toll free). Persons with a hearing or speech
disability with access to TTY/TDD equipment can call
304-579-4827 (not toll free).