b"PRE-PRINTED 1099 FORMSINDIVIDUAL LASER PACKS1099INT INTEREST 1099DIV DIVIDEND9292 VOID CORRECTED 9191 VOIDCORRECTED DETACH BEFORE MAILINGDETACH 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 or foreign postal code, and telephone no. or foreign postal code, and telephone no. Interest$Dividends and 1 Interest income 2021 Income 1b 2021 Distributions $ Form1099-INT $Form1099-DIV 2 Early withdrawal penalty Copy A $2aTotal capital gain distr. $2bUnrecap. 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Payers RTN (optional) $ Certainor foreign postal code, and telephone no. 11Exempt-interest dividends12 bond interest dividends OMB No. 1545-0110Dividends andNotice, see the OMB No. 1545-0112 Returns. 6 Foreign tax paid 5Section 199A dividendsrequirement $ 12 Bond premium on Treasury obligations $ 13 Bond premium on tax-exempt bond Information 9 Interestand Paperworkrequirement $$$1b 2021 Distributions2021 General 1 Interest income $Returns.interest Reduction Act$7Foreign tax paid8Foreign country or U.S. possessionAccount number (see instructions) 2nd TIN not. $ 14 Tax-exempt and tax credit$ 15 State16$ $ 2021 $ Income Notice, see the Account number (see instructions)2nd TIN not. 13State 14 $15State tax withheld Form9 1099-DIV10 Noncash liquidation distributionsInstructions for Certain 8 Tax-exempt interestbond CUSIP no. $ $ 17 State tax withheld 11 Bond premium 2021 General$2aTotal capital gain distr. $$Cash liquidation distributions Copy BInformation Form1099-INT2 Early withdrawal penalty 10 Market discount 13Copy B Instructions forCertainForm1099-DIVLDA PAYERS TIN5130 www.irs.gov/Form1099DIV $$2cSection 1202 gain$2bUnrecap. 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Sec. 1250 gainCopy CPAYERS TIN RECIPIENTS TIN $ $ PAYERS TINRECIPIENTS TIN $$2cSection 1202 gain2dCollectibles (28%) gainFor PayerForm1099-INT LIB (keep for your records) 5121 www.irs.gov/Form1099INT Department of the Treasury - Internal Revenue Service Form1099-DIVLDB (keep for your records)5131 www.irs.gov/Form1099DIV Department of the Treasury - Internal Revenue Service and/or State 3 Interest on U.S. Savings Bonds and Treas. obligations For Payer $2eSection 897 ordinary dividends $2fSection 897 capital gain Copy 1 or Copy 2$ Copyand/or1orCopy2 RECIPIENT'S name, stret adres, city or town, state or province, country, and ZIP or foreign postal code $3Nondividend distributions$4Federal income tax withheldStateRECIPIENT'Sname,stretadres,cityortown,stateorprovince,country,andZIPorforeignpostalcode 4 Federal income tax withheld5 Investment expenses$ $ $$For Privacy Act 6 Foreign tax paid 7 Foreign country or U.S. possession For Privacy Act5Section 199A dividends 6Investment expensesand Paperwork $ and Paperwork$$Reduction Act Notice, see the 8 Tax-exempt interest 9 interest Reduction Act7Foreign tax paid8Foreign country or U.S. possession 2021 General Notice, see the$Instructions for $ 10 Market discount $ 11 Bond premium 2021 General 9Cash liquidation distributions10 Noncash liquidation distributionsCertain Instructions forCertain$$Information 12 Bond premium on Treasury obligations13 Bond premium on tax-exempt bond Information requirement 11Exempt-interest dividends12bond interest dividends Returns. requirement $ $ Returns. $ $ $$ Account number (see instructions) 2nd TIN not.14 Tax-exempt and tax credit15 State1617 State tax withheld Account number (see instructions)2nd TIN not. 13State 1415State tax withheldbond CUSIP no. $ $ $ $ Form1099-INT LIC 5122 www.irs.gov/Form1099INT Department of the Treasury - Internal Revenue Service Form1099-DIVLDC 5132 www.irs.gov/Form1099DIV Department of the Treasury - Internal Revenue ServiceApex DWMR or DWMRS Apex DWMR or DWMRSTFP 77771 or 77772 required envelope TFP 77771 or 77772 required envelopeAPEX Sheets per packTFP Forms per pack50s500s100s1000sFORM DESCRIPTIONLIALIA50051205120BLaser 1099INT Federal Copy A1 page equals 2 formsLIBLIB50051215121BLaser 1099INT Recipient Copy B1 page equals 2 formsLICLIC50051225122BLaser 1099INT Payer Copy C and/or State Copy1 page equals 2 formsLDALDA50051305130BLaser 1099DIV Federal Copy A1 page equals 2 formsLDBLDB50051315131BLaser 1099DIV Recipient Copy B1 page equals 2 formsLDCLDC50051325132BLaser 1099DIV Payer Copy C and/or State Copy1 page equals 2 forms31"