PAYER'S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.
1a
Total ordinary dividends
$
2a
Total capital gain distr
$
OMB No. 1545-0110
Form 1099-DIV
(Rev. January 2024)
Dividends and Distributions
2b
Federal income tax withheld
$
Copy BFor Recipients
2c
Section 1202 gain
$
2e
Section 897 ordinary dividends
$
2d
Collectibles (28%) gain
$
2f
Section 897 capital gain
$
RECIPIENT'S name
Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
11 FATCA filing requirement
3
Nondividend distributions
$
5
Section 199A dividends
$
9
Cash liquidation distributions
$
12
Exempt-interest dividends
$
4
income tax withheld
$
6
Investment expenses
$
8
Foreign country or U.S. possession
$
10
Noncash liquidation distributions
$
13
Specified private activity bond interest dividends
$
This is important tax information and is being furnished to the IRS. 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.
Account number (see instructions)
15
State identification no
