b"1099 PRE-PRINTED FORMSIndividual Laser Packs1099-INT (INTEREST) 1099-DIV (DIVIDEND)9292 VOID CORRECTED 9191 VOIDCORRECTEDor foreign postal code, and telephone no. Form1099-INT Interest DETACH BEFORE MAILING or foreign postal code, and telephone no.$Form1099-DIVDividends and DETACH BEFORE MAILINGRESISTANT INKSUSING HEAT MANUFACTURED ON OCR LASER BOND PAPER USING HEAT RESISTANT INKSON OCR LASER BOND PAPERRESISTANTPAYERS name, street address, city or town, state or province, country, ZIP Payers RTN (optional) OMB No. 1545-0112 PAYERS name, street address, city or town, state or province, country, ZIP 1aTotal ordinary dividendsOMB No. 1545-0110 1 Interest income (Rev. January 2022) Income 1b (Rev. January 2022) Distributions For calendar year For calendar year$ 20 $202 Early withdrawal penalty Copy A $2aTotal capital gain distr. $2bUnrecap. Sec. 1250 gainCopy AFor Copy APAYERS TIN RECIPIENTS TIN$ PAYERS TIN RECIPIENTS TIN 2cSection 1202 gain2dCollectibles (28%) gainInternal Revenue 3 Interest on U.S. Savings Bonds and Treasury obligations Internal Revenue For$2eSection 897 ordinary dividends $2fSection 897 capital gainService Center $ Service Center $$File with Form 1096.RECIPIENTS name 4 Federal income tax withheld5 Investment expenses File with Form 1096. RECIPIENTS name3Nondividend distributions 4Federal income tax withheldFor Privacy Act $ $ $$and Paperwork Street address (including apt. no.) 6 Foreign tax paid 7 Foreign country or U.S. possession For Privacy ActStreet address (including apt. no.)$5Section 199A dividends $6Investment expensesReduction Act $ 8 Tax-exempt interest 9 interest and Paperwork7Foreign tax paid8Foreign country or U.S. possession Notice, see the Reduction Actcurrent General City or town, state or province, country, and ZIP or foreign postal code $ 10 Market discount CORRECTED (if checked) Notice, see theCity or town, state or province, country, and ZIP or foreign postal code $CORRECTED (if checked) Instructions for $ 11 Bond premium current General PAYERS name, street address, city or town, state or province, country, ZIP 9Cash liquidation distributions $10 Noncash liquidation distributions Certain PAYERS name, street address, city or town, state or province, country, ZIPPayers RTN (optional) Instructions forCertain or foreign postal code, and telephone no. 11 requirement $12Exempt-interest dividends13 $1aTotal ordinary dividendsInformationDividends andDETACH BEFORE MAILINGDETACH BEFORE MAILINGINKSUSING HEAT MANUFACTURED ON OCR LASER BOND PAPER USING HEAT RESISTANT INKSMANUFACTUREDRESISTANTor foreign postal code, and telephone no. OMB No. 1545-0112 Exempt-interest dividends bond interest dividends OMB No. 1545-0110 requirement $ 12Bond premium on Treasury obligations $ 13 Bond premium on tax-exempt bond Information Interest1b FormReturns.Distributions Form1099-INT 1099-DIVReturns.$ $ 1 Interest income (Rev. January 2022) Income $$(Rev. January 2022)For calendar yearAccount number (see instructions) 2nd TIN not.14 Tax-exempt and tax credit15 State1617 State tax withheld Account number (see instructions)2nd TIN not.14State 1516State tax withheld For calendar yearbond CUSIP no. $ 2 Early withdrawal penalty $ 20 Copy B Form(Rev. 1-2022) PAYERS TINRECIPIENTS TIN $$2aTotal capital gain distr. $20 Copy B $2bUnrecap. Sec. 1250 gain $ 41-0852411 www.irs.gov/Form1099DIV $$2cSection 1202 gain2dCollectibles (28%) gainFor Recipient $ Form1099-INT(Rev. 1-2022) PAYERS TIN RECIPIENTS TIN Department of the Treasury - Internal Revenue Service For Recipient 1099-DIVDepartment of the Treasury - Internal Revenue Service41-0852411 www.irs.gov/Form1099INT $Do Not Cut or Separate Forms on This PageDo Not Cut or Separate Forms on This Page DoNotCutorSeparateFormsonThisPage DoNotCutorSeparateFormsonThisPage3 Interest on U.S. Savings Bonds and Treasury obligations $$BOND PAPERON OCR LASERMANUFACTURED2eSection 897 ordinary dividends2fSection 897 capital gain $ $$ 9292 RECIPIENT'S VOID tadres,city CORRECTED or or country,andZIPorforeignpostalcode $ 4 Federal income tax withheld $ 5 Investment expenses This is important tax9191 RECIPIENT'S name, stret adres, city or town, state or province, country, and ZIP or foreign postal code $3Nondividend distributions$4Federal income tax withheldThis is important tax or foreign postal code, and telephone no. name,stre town,stateprovince, 6 Foreign tax paid 7 Foreign country or U.S. possession information and isor foreign postal code, and telephone no.VOIDCORRECTED OMB No. 1545-01106Investment expensesbeing furnished to PAYERS name, street address, city or town, state or province, country, ZIP Payers RTN (optional) OMB No. 1545-0112 being furnished to thePAYERS name, street address, city or town, state or province, country, ZIP 1aTotal ordinary dividends5Section 199A dividends information and is IRS. If you are 1 Interest income $ 1099-INT 9 Interestreturn, a negligence$1b Form $1099-DIVDividends andthe IRS. If you are Form$ 8 Tax-exempt interest 7Foreign tax paid8Foreign country or U.S. possession return, a negligence (Rev. January 2022) interest penalty or other(Rev. January 2022) Distributionssanction may be Income sanction may beFor calendar year penalty or other $ 2 Early withdrawal penalty $ For calendar year $ 11 Bond premiumimposed on you if$2aTotal capital gain distr. $9 VOIDCORRECTED imposed on you if 10 Market discount CORRECTED this income is20 Cash liquidation distributions10 Noncash liquidation distributions VOID 2bUnrecap. Sec. 1250 gain$1aTotal ordinary dividendsthis income is taxable OMB No. 1545-0110 and the IRS 20PAYERS name, street address, city or town, state or province, country, ZIP Payers RTN (optional) taxable and the IRS$Copy A determines that it hasDETACH BEFORE MAILINGDETACH BEFORE MAILINGINKSUSING HEAT MANUFACTURED ON OCR LASER BOND PAPER USING HEAT RESISTANT INKSON OCR LASER BOND PAPERor foreign postal code, and telephone no.Bond premium on Treasury obligations13Copy A OMB No. 1545-0112 or foreign postal code, and telephone no.13 $1b ForForm1099-DIVDividends and PAYERS TIN RECIPIENTS TIN$ requirement $ $ Bond premium on tax-exempt bond determines that it hasInterestPAYERS TIN RECIPIENTS TIN PAYERS name, street address, city or town, state or province, country, ZIP 12 Internal Revenuenot been reported. not been reported. $$bond interest dividendsForForm1099-INT $2cSection 1202 gain 11requirement2dCollectibles (28%) gain Exempt-interest dividends Service Center(Rev. 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PAYERS TIN Foreign country or U.S. possession Department of the Treasury - Internal Revenue Service For Payer Street address (including apt. no.)PAYERS TIN$8 Investment expensesand Paperwork$2fSection 897 capital gainand/or State $ (keep for your records) www.irs.gov/Form1099INT $ 3 Interest on U.S. Savings Bonds and Treasury obligations (keep for your records)www.irs.gov/Form1099DIV Reduction ActCopy 1 or Copy 2Department of the Treasury - Internal Revenue Service6 Foreign tax paid RECIPIENTS TIN For Privacy Act$7Foreign tax paidForeign country or U.S. possession $2cSection 1202 gain 8 Tax-exempt interest 9 interest and PaperworkCity or town, state or province, country, and ZIP or foreign postal code RECIPIENT'S name, stret adres CORRECTED (if checked) Notice, see the$4Federal income tax withheld For Privacy Act Reduction Actcurrent General 2eSection 897 ordinary dividendsCity or town, state or province, country, and ZIP or foreign postal code RECIPIENT'Sname,stretadres,cityCORRECTED (if checked)or or or postal Notice, see the$ 5 Investment expenses Copyand/or1or State2 $9 , city or town, state or province, country, and ZIP or foreign postal code $3Nondividend distributions$and Paperwork $ town,stateprovince,country,andZIPforeign code $ 4 Federal income tax withheld Copy Cash liquidation distributions10 Noncash liquidation distributions Instructions for Certain $ current General10 Market discount 11 Bond premium Instructions for PAYERS name, street address, city or town, state or province, country, ZIP 1aTotal ordinary dividendsInformation$6Investment expensesReduction Act PAYERS name, street address, city or town, state or province, country, ZIPPayers RTN (optional) $ 6 Foreign tax paid 7 Foreign country or U.S. possession For Privacy Actor foreign postal code, and telephone no.12Exempt-interest dividends $13bond interest dividends Form$5Section 199A dividends DistributionsNotice, see the or foreign postal code, and telephone no. OMB No. 1545-0112 11 requirement $$OMB No. 1545-0110Dividends and requirement $ 12Bond premium on Treasury obligations $ 13 Bond premium on tax-exempt bond Certain 9 Interestand Paperwork1b $Returns.8Foreign country or U.S. possessioncurrent General Information 1099-DIV1 Interest income Form1099-INT interest Reduction Act$$(Rev. January 2022)$Returns. 7Foreign tax paid 8 Tax-exempt interest$ bond CUSIP no. $ 15 State16$ $ (Rev. 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Sec. 1250 gain$13bond interest dividends Returns. 10 Market discount 9 MANUFACTUREDForm1099-INT(Rev. 1-2022) LIA PAYERS TIN www.irs.gov/Form1099INT Department of the Treasury - Internal Revenue Service For Recipient Information1099-DIVDepartment of the Treasury - Internal Revenue Service $ For Recipient $ requirement Bond premium on Treasury obligations Bond premium on tax-exempt bond Returns. $2cSection 1202 gain 11requirement2dCollectibles (28%) gain 12Exempt-interest dividends3 Interest on U.S. Savings Bonds and Treasury obligations12 $ Account number (see instructions) $ 2nd TIN not. $ 14 Tax-exempt and tax credit$ 15 State16$ 17 State tax withheld RECIPIENT'S name, stret adres Account number (see instructions)$2nd TIN not. 2fSection 897 capital gain$16State tax withheld(Rev. 1-2022) $ 6 Foreign tax paid $ 7bond CUSIP no. being furnished to the, city or town, state or province, country, and ZIP or foreign postal code $3Nondividend distributions$4 14State 15 This is important tax RECIPIENT'Sname,stretadres,cityortown,stateorprovince,country,andZIPorforeignpostalcode 4 Federal income tax withheld5 Investment expenses This is important tax(Rev. 1-2022) $Federal income tax withheld$being furnished to information and is$ information and is Form1099-INTForeign country or U.S. possession IRS. If you areForm1099-DIV5Section 199A dividendswww.irs.gov/Form1099DIV6Investment expensesDepartment of the Treasury - Internal Revenue Servicewww.irs.gov/Form1099INT Department of the Treasury - Internal Revenue Service$ return, a negligence$7Foreign tax paid$8Foreign country or U.S. possession the IRS. If you are return, a negligence 8 Tax-exempt interest 9 interest penalty or otherpenalty or other sanction may besanction may be $ VOID CORRECTEDimposed on you if$9Cash liquidation distributions Noncash liquidation distributions this income is taxable $ this income isVOIDCORRECTED imposed on you if 10 Market discount 11 Bond premium taxable and the IRSPAYERS name, street address, city or town, state or province, country, ZIP 101aTotal ordinary dividendsdetermines that it has and the IRS or foreign postal code, and telephone no. OMB No. 1545-0112 not been reported. PAYERS name, street address, city or town, state or province, country, ZIPPayers RTN (optional) determines that it hasor foreign postal code, and telephone no. 11 requirement $12Exempt-interest dividends $13bond interest dividends OMB No. 1545-0110Dividends and requirement $ 12Bond premium on Treasury obligations $ 13 Bond premium on tax-exempt bond not been reported. Interest$1b Form1099-DIVDistributions Form1099-INT$ $ 1 Interest income (Rev. January 2022) Income $$(Rev. January 2022)For calendar yearAccount number (see instructions) 14 Tax-exempt and tax credit15 State1617 State tax withheld Account number (see instructions)14State 1516State tax withheld For calendar yearbond CUSIP no. $ 2 Early withdrawal penalty $ 20 Copy C $$2aTotal capital gain distr. $20 Copy CRECIPIENTS TIN $ $ PAYERS TINRECIPIENTS TIN $$2cSection 1202 gain2bUnrecap. Sec. 1250 gainFor PayerForm1099-INT(Rev. 1-2022)LIBPAYERS TIN 5121www.irs.gov/Form1099INT Department of the Treasury - Internal Revenue Service Form1099-DIV(Rev. 1-2022)LDB (keep for your records)5131 www.irs.gov/Form1099DIV Department of the Treasury - Internal Revenue Service and/or State (keep for your records) 2dCollectibles (28%) gain 3 Interest on U.S. Savings Bonds and Treasury obligations For Payer $2eSection 897 ordinary dividends $2fSection 897 capital gain Copy 1 or Copy 2Copyand/or1or State RECIPIENT'S name, stret adres, city or town, state or province, country, and ZIP or foreign postal code $3Nondividend distributions$4Federal income tax withheld$ Copy2RECIPIENT'Sname,stretadres,cityortown,stateorprovince,country,andZIPorforeignpostalcode 4 Federal income tax withheld5 Investment expenses$ $ $$For Privacy Act 6 Foreign tax paid 7 Foreign country or U.S. possession For Privacy Act5Section 199A dividends 6Investment expensesand Paperwork $ and Paperwork$$Reduction Act 8 Tax-exempt interest 9 interest Reduction Act7Foreign tax paid8Foreign country or U.S. possession Notice, see the current General $ 10 Market discount $ 11 Bond premium Notice, see the$9Cash liquidation distributions10 Noncash liquidation distributionsInstructions for current General Certain 12 Bond premium on Treasury obligations13 Bond premium on tax-exempt bond Instructions forCertain $12Exempt-interest dividends $13bond interest dividends Information Information Returns. requirement $ $ Returns. 11requirement$ $ $$ Account number (see instructions) 2nd TIN not.14 Tax-exempt and tax credit15 State1617 State tax withheld Account number (see instructions)2nd TIN not.14State 1516State tax withheldbond CUSIP no. $ $ $ $ Form1099-INT(Rev. 1-2022) LIC 5122 www.irs.gov/Form1099INT Department of the Treasury - Internal Revenue Service Form1099-DIV(Rev. 1-2022) LDC 5132 www.irs.gov/Form1099DIV Department of the Treasury - Internal Revenue ServiceRequired Envelope: Required Envelope:APEX: DWMR or DWMRS APEX: DWMR or DWMRSTFP: 77771 or 77772 TFP: 77771 or 77772APEX - Sheets per packTFP - Forms per pack50s500s100s1000sFORM DESCRIPTIONLIALIA50051205120B1099-INT Federal Copy A1 Page Equals 2 FormsLIBLIB50051215121B1099-INT Recipient Copy B1 Page Equals 2 FormsLICLIC50051225122B1099-INT Payer Copy C and/or State Copy1 Page Equals 2 FormsLDALDA50051305130B1099-DIV Federal Copy A1 Page Equals 2 FormsLDBLDB50051315131B1099-DIV Recipient Copy B1 Page Equals 2 FormsLDCLDC50051325132B1099-DIV Payer Copy C and/or State Copy1 Page Equals 2 Forms30"