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January 2022)yearFor calendar 1099-MISC20 Other income Federal income tax withheld Copy 29191 VOIDCORRECTED CORRECTED (if checked) VOIDCORRECTED Do Not Staple 6969 Fishing boat proceeds Medical and health care payments To be filed statewith L4PSBCPAYERS name, street address, city or town, state or province, country, ZIP$1aTotal ordinary dividendsOMB No. 1545-0110PAYERS name, street address, city or town, state or province, country, ZIP$1aTotal ordinary dividendsOMB No. 1545-0110PAYERS name, street address, city or town, state or province, country, ZIP$1aTotal ordinary dividendsOMB No. 1545-0110Form1096 Annual Summary and Transmittal of OMB No. 1545-0108 RECIPIENTS name, street address (including apt. no.), city or town, state or province, country, and ZIP or foreign postal code $ 7 of consumer products$ $ 8 dividends or payments interest in lieu of recipients 1b Form1099-DIVDividends and INKS 1b Form1099-DIV Dividends and DETACH BEFORE MAILINGUSING HEATINKS 1b Form1099-DIVDividends and DETACH BEFORE MAILINGUSING HEATINKS U.S. Information Returns 2023DETACH BEFORE MAILING PRINTED IN USA 9 Payer made $5,000 direct or moresalesto 10 Substitutey paid to an DETACH BEFORE MAILINGUSING HEATMANUFACTUREDMANUFACTURED ON OCR LASER BOND PAPER USING HEAT RESISTANT INKS MW353 or foreign postal code, and telephone no.or foreign postal code, and telephone no.or foreign postal code, and telephone no.income when tax required.return, RESISTANTRESISTANTRESISTANTDepartment of the Treasurytotaling (Rev. 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Box 219256 11requirement 12Exempt-interest dividends13bond interest dividends 11requirement 12Exempt-interest dividends13bond interest dividends 11requirement 12Exempt-interest dividends13bond interest dividends the name and TIN used on your 94X series tax return(s) or you may beMontana, Nebraska, Nevada, North Kansas City, MO 64121-9256 FACE; PERFS AS MARKED; SCREENS 20% & 50%PRINTED IN USADakota, Oklahoma, Oregon, South Account number (see instructions)2nd TIN not.$14State 15 $16State tax withheld Account number (see instructions)$14State 15 $16State tax withheld Account number (see instructions)2nd TIN not.$14State 15 $16State tax withheld subject to information return penalties. Do not use the name and/or TIN ofUtah, Washington, Wisconsin, Wyoming your paying agent or service bureau. 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The only acceptable method of electronically through the FIRE February 28, 2024.returns listed on this form in box 6 with the IRS isFor Payer PAYERS TIN RECIPIENTS TIN 3Capital gain (included in 4Federal income tax Internal Revenue3Capital gain (included inFederal income tax income on your3Capital gain (included inFederal income tax income on your3Capital gain (included inFederal income tax System. See Pub. 1220.d/orreturn. If thisreturn. If thisCaution:Tax State,anCity,lPurpose of form. 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Box 149213 SEP/2023 General Massachusetts, Mississippi, New code(s) SIMPLE Instructions for CertainThis information isSIMPLE This information isSIMPLE Information Returns. part F in the 2023 General Instructions for CertainHampshire, New Jersey, New Mexico,Austin, TX 78714-9213information, seeInstructions for% CertainVermont, VirginiaInformation City or town, state or province, country, and ZIP or foreign postal code9aYour percentage of total 9bTotal employee contributions Information9aYour percentage of total 9bTotal employee contributions being furnished to the IRS. 9aYour percentage of total 9bTotal employee contributions being furnished to the IRS. 9aYour percentage of total 9bTotal employee contributions Returns. Alaska, Colorado, Hawaii, Idaho, within 5 years Roth contrib. requirement$ distribution %$ within 5 years Returns. Roth contrib. 12 requirement$ 14 distribution %$ 15State/Payers state no.10 $ 16State distribution 111st year of desig. 12 requirement$ 14 distribution %$ 15State/Payers state no.10Amount allocable to IRR111st year of desig. 12 requirement$ 14 distribution %$ returns. $ 16State distribution Illinois, Indiana, Iowa, Kansas,Internal Revenue Service Center Who must le. 10Amount allocable to IRR111st year of desig. 12 14State tax withheld 15State/Payers state no.10Amount allocable to IRR111st year of desig.State tax withheld Amount allocable to IRRState tax withheld 16State distribution State tax withheld 15State/Payers state no. Michigan, Minnesota, Missouri,P.O. Box 219256 16State distribution Caution:Montana, Nebraska, Nevada, North Kansas City, MO 64121-9256$ within 5 years Roth contrib. within 5 years Roth contrib. the name and TIN used on your 94X series tax return(s) or you may beDakota, Oklahoma, Oregon, South $ subject to information return penalties. Do not use the name and/or TIN ofCarolina, South Dakota, Tennessee,$ $ $ $ $ $ $ $ $ $ $ $ Utah, Washington, Wisconsin, Wyoming Account number (see instructions) 13Date of17Local tax withheld 18Name of localityAccount number (see instructions) 13Date of17Local tax withheld 18Name of localityAccount number (see instructions) 13Date of17Local tax withheld 18Name of localityAccount number (see instructions) 13Date of17Local tax withheld 18Name of locality your paying agent or service bureau.19Local distribution 19Local distribution 19Local distribution 19Local distributionpayment$ $ payment$ $ payment$ $ payment$ $Form 1099-R LRA 41-0852411 5140 $ Form $ LRB 5141 www.irs.gov/Form1099R $ Form $ LRB 5141 www.irs.gov/Form1099R $ Form $ LRD1 5143 www.irs.gov/Form1099R $ For more information and the Privacy Act and Paperwork Reduction Act Notice,L1096 41-0852411 5100 Form1096(2023) ZFold ZFold$(3) Transmittal 1096 forms are included with each set SEE REVERSE INSTRUCTIONSSIDE FOR OPENINGSEE REVERSE INSTRUCTIONS SIDE FOR OPENING Important Tax Document Enclosed SEE REVERSE INSTRUCTIONS SIDE FOR1099-R 1099-R 1099-R see the 2023 General Instructions for Certain Information Returns. OPENINGSEE REVERSE INSTRUCTIONSSIDE FOR OPENINGwww.irs.gov/Form1099R Department of the Treasury - Internal Revenue Service Department of the Treasury - Internal Revenue Service Department of the Treasury - Internal Revenue Service Department of the Treasury - Internal Revenue ServiceFirst-Class MailAPEX 1099-DIV LASER PACKAGED SETAPEX 1099-R LASER PACKAGED SET STANDARD SETS (50 Sheets for 100 Recipients) STANDARD SETS w/ Envelopes (50 Sheets for 100 Recipients) APEX - Sheets per packTFP - Forms per pack959333-Part SET includes: (50 Sheets EACH) 1099-DIV Copy A, B, C 95944E4-Part SET includes: (50 Sheets EACH) 1099-R Copy A, B, C, D,500s500sFORM DESCRIPTION959344-Part SET includes: (50 Sheets EACH) 1099-DIV Copy A, B, C, C + DWMR (100) PS353511311" Printed 1099-MISC Copy B, 2Z-Fold Simplex1 Page Equals 1 Form*VALUE SETS w/ Self-Seal Envelopes (10 Sheets for 20 Recipients) 95946E6-Part set includes: (50 Sheets EACH) 1099-R Copy A, B, C, D, 1, 2,NECPS353NEC511311" Printed 1099-NEC 2-Up Horizontal Copy B, 2Z-Fold Simplex1 Page Equals 1 Form* 95910ES4-Part SET includes: (10 Sheets EACH) 1099-DIV Copy A, B, C, C,+ DWMR (100) N/A511911" Blank 1099 3-Up HorizontalZ-Fold1 Page Equals 1 Form+ DWMRS (20) PSBMISC550111" Blank 1099-MISC Copy B, 2 w/ BackerZ-Fold1 Page Equals 1 FormNECPSBMISCNEC550111" Blank 1099-NEC w/ Backer InstructionsZ-Fold 1 Page Equals 1 FormPSN11Z522911" Blank 1099 2-UpZ-Fold Simplex1 Page Equals 1 FormPSN14EZN/A14" Blank 1099 Multi-Purpose 2-Up w/ Screened BackEccentric Z-Fold1 Page Equals 1 FormPSB80650N/A14" Blank Universal1 Page Equals 1 FormPSB99ZN/A11" Blank 1099 3-Up w/ Screened Back1 Page Equals 1 Form50 51'