b"PRE-PRINTED 1099 FORMS1X XWXIDE CONTINUOUS1099DIV COPY A 1099MISC COPY A 10969191 VOIDCORRECTED 9595 VOID CORRECTED Do Not Staple 6969 OMB No. 1545-0108PAYERS 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, ZIP1 Rents OMB No. 1545-0115 Form1096 Annual Summary and Transmittal ofor foreign postal code, and telephone no.or foreign postal code, and telephone no. (Rev. February 2021)Dividends andMiscellaneousInternal Revenue Service U.S. Information Returns 2021$1b 2021 Distributions$ 2 Royalties 2021 Information Department of the Treasury FILERS nameCORRECTED (if checked)$Form1099-DIV$ 3 Other income 1099-MISC 1 Rents Copy A OMB No. 1545-0115 Street address (including room or suite number)2aTotal capital gain distr. 2bUnrecap. Sec. 1250 gainCopy A PAYERS name, street address, city or town, state or province, country, ZIP Form or foreign postal code, and telephone no. 4 Federal income tax withheldPAYERS TIN RECIPIENTS TIN $2cSection 1202 gain$2dCollectibles (28%) gainForPAYERS TIN RECIPIENTS TIN $ 5 Fishing boat proceeds $ 6 Medical and health care payments $ 2 Royalties ForMiscellaneous $Internal RevenueInternal Revenue2021 Information City or town, state or province, country, and ZIP or foreign postal code$Service CenterService CenterRECIPIENTS name$2eSection 897 ordinary dividends $2fSection 897 capital gainFile with Form 1096. 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Under penalties of perjury, I declare that I have examined this return and accompanying documents and, to the best of my knowledge and belief, they are true, correct, DoNotCutorSeparateFormsonThisPage DoNotCutorSeparateFormsonThisPage Do Not Cut or Separate Forms on This PageDo Not Cut or Separate Forms on This Page $ 17 State income and complete.$15 State tax withheld 16 State/Payers state no.2PT 10962M FOR $ $Title Date$ $ Signature9191 VOIDCORRECTED OMB No. 1545-01101099MISC COPY B VOID Form1099-MISC (keep for your records) www.irs.gov/Form1099MISC Department of the Treasury - Internal Revenue Service Instructions9595 CORRECTEDPAYERS name, street address, city or town, state or province, country, ZIP 1aTotal ordinary dividendsPAYERS name, street address, city or town, state or province, country, ZIP1 Rents OMB No. 1545-0115 Future developments. For the latest information about developments or foreign postal code, and telephone no.or foreign postal code, and telephone no. related to Form 1096, such as legislation enacted after it wasform must be the same as those you enter in the upper left area of Dividends andMiscellaneous $1b 2021 Distributions$ 2 Royalties 2021 Information published, go to www.irs.gov/Form1096. Forms 1097, 1098, 1099, 3921, 3922, 5498, or W-2G.Reminder. The only acceptable method of electronicallyWhen to le. File Form 1096 as follows.9595 CORRECTED (if checked) information returns listed on this form in box 6 with the IRS is through the FIRE System. See Pub. 1220. $Form1099-DIVPAYERS name, street address, city or town, state or province, country, ZIP1 Rents OMB No. 1545-0115 Purpose of form. Use this form to transmit paper Forms 1097, 1098,February 28, 2022.$ Form 1099-MISCor foreign postal code, and telephone no. Copy A 1099, 3921, 3922, 5498, and W-2G to the IRS. PAYERS TIN RECIPIENTS TIN $2aTotal capital gain distr. $2bUnrecap. Sec. 1250 gainCopy AForPAYERS TIN RECIPIENTS TIN $ 3 Other income $ 4 Federal income tax withheld $ 2 Royalties For2021 MiscellaneousCaution:Where To FileInternal RevenueMedical and health care payments Internal RevenueInformation$2cSection 1202 gain$2dCollectibles (28%) gainAPEX DWMR5 Fishing boat proceeds 6APEX DW19$ Form 1099-MISC Copy B electronically but fail to do so, and you do not have an approvedfollowing. Use the following Service CenterService Center waiver, you may be subject to a penalty. The Taxpayer First Act of 2eSection 897 ordinary dividends2fSection 897 capital gainFile with Form 1096. $ $ $ File with Form 1096. 4 Federal income tax withheld 2019, enacted July 1, 2019, authorized the Department of theIf your principal business, ofce $$3 Other income Treasury and the IRS to issue regulations that reduce the 250-returnor agency, or legal residence inaddressrequirement for 2021 tax returns. 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If you are Returns.requirement $11Exempt-interest dividends12 bond interest dividends Returns.Account number (see instructions) requirement 2nd TIN not. $ payments 14compensation $ 9 Crop insurance proceeds $ attorney return, a negligence41-0852411 Form1096(2021)$$1099INT, 1099K,13 Excess golden parachute$ 1099PATR, 1099S penalty or otherFor more information and the Privacy Act and Paperwork Reduction Act Notice, FOR $ 11 Fish purchased for resale 12 Section 409A deferrals sanction may besee the 2021 General Instructions for Certain Information Returns.imposed on you if Account number (see instructions)2nd TIN not. 13State 14 $15State tax withheld 1099MISC, 1099R 15 State tax withheld 16 State/Payers state no. 17 State income $ compensation this income is $ $$ 14taxable and the IRS $ $ payments determines that it $Account number (see instructions) requirement 13 Excess golden parachutehas not been Form1099-DIV41-0852411 www.irs.gov/Form1099DIV Department of the Treasury - Internal Revenue Service Form1099-MISC 41-0852411 www.irs.gov/Form1099MISC Department of the Treasury - Internal Revenue Service $ reported.$15 State tax withheld 16 State/Payers state no. 17 State income$ $$ $Form1099-MISC (keep for your records) www.irs.gov/Form1099MISC Department of the Treasury - Internal Revenue ServiceAPEXTFPFORM DESCRIPTIONTC-A4715844-Part 1099A 1 Wide Carbonless Copy A, State, B, CTC-B4715744-Part 1099B 1 Wide Carbonless Copy A, State, B, CTC-C4718444-Part 1099C 1 Wide Carbonless Copy A, State, B, CTC-D4715244-Part 1099DIV 1 Wide Carbonless Copy A, B, CTC-G4715344-Part 1099G 1 Wide Carbonless Copy A, State, B, CTC-I4715044-Part 1099INT 1 Wide Carbonless Copy A, B, CTC-M3715433-Part 1099MISC 1 Wide Carbonless Copy A, B, C*TC-M4715444-Part 1099MISC 1 Wide Carbonless Copy A, State, B, C*TC-M5715455-Part 1099MISC 1 Wide Carbonless Copy A, State, B, 2, C*TC-O4715644-Part 1099OID 1 Wide Carbonless Copy A, State, B, CTC-P4715544-Part 1099PATR 1 Wide Carbonless Copy A, State, B, CTC-R4715944-Part 1099R 1 Wide Carbonless Dated Copy A, B, C, DTC-MR4862144-Part 1099R Carbonless Electronic Filing Dated Copy B, C, 2, DTC-S4716044-Part 1099S 1 Wide Carbonless Copy A, State, B, CTC18-3716833-Part 1098 1 Wide Carbonless Copy A, B, CTC18-4716844-Part 1098 1 Wide Carbonless Copy A, State, B, C1096109622-Part 1096 Carbonless Annual Summary & Transmittal Of U.S. Information Returns5 Transmittal 1096 forms are included with each Red Federal Copy A form orderPARTS DESCRIPTION 1099 & 1098 FORMS 1099R 1099S 1098 5498 PAYERS COPIESPAYERS COPIES PAYERS COPIES PAYERS COPIESCopy AFor Internal Revenue Service Copy AFor Internal Revenue Service Copy AFor Internal Revenue Copy AFor Internal Revenue Service StateFor State Copy StateFor State Copy ServiceCopy 1For State, City or Copy CCopy CFor Recipient/Lender/Filer/Donors Records Copy CFor Trustee or IssuerLocal Tax Dept. Filer, Payer, Creditor, Lender orCopy DFile Copy File CopyRECIPIENTS COPY PARTICIPANTS COPYRecipients Copies RECIPIENTS COPIES Copy BFor Payer/Borrower/Student/Donor Copy BFor ParticipantCopy BCopy DFor DoneeCopy BFor Recipient to file with IRS Transferor, Debtor, Recipient or Copy CFor Recipients Records BorrowerCopy 2For Recipient to file with State Copy 2For Recipient to file withState, City or Local Tax Dept.48"