0 CORRECTED if checked

0 CORRECTED if checked PAYER'S name. street address. city or town. state or province, country. ZIP or foreign postal code. and telephone no. PAYERS TIN RECIPIENT'S TIN RECIPIENTS name Street address (including apt. no.) City or town. state or province. country. and ZIP or foreign postal code FATCA film requirement 0 Account number (see instructions) Form 1099-DIV (keep for your records) to Total ordinary dividends $ lb Qualified dividends $ 2a Total capital gain distr. 2c Section 1202 gain $ 3 Nondividend distributions $ 5 Section 199A dividends $ 7 Foreign tax paid $ 9 Cash liquidation distributions $ 11 Exempt-interest dividends $ 13 State USOPOOMMenna OMB No. 1505-0110 2018 Form 1099-DIV Dividends and Distributions 2b Unrecap. Sec. 1250 gain 2d Collectibles (28%) gain $ 0 Federal ncorne tax vnthheld $ 6 Investment expenses $ 8 Roan country ar U.S. possesses 10 Noncash liquid: non chanty:an $ 12 Specified private activity bond interest dividends $ 15 State tax withheld $ Copy B For Recipient 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. wwwits.goviform1099DIV Department of the Treasury - Internal Revenue Service EFTA01222594