CORRECTED if check PAYER'S name. street address. city or town. state or province, country. ZIP or foreign postal code. and telephone no. PAYER'S federal identification number RECIPIENT'S identification number RECIPIENT'S name Street address fincludirg apt. no.) City or town. state or province. country. and ZIP or foreign postal code FATCA filng requirement 0 Account number (see instructions) Form 1099-DIV (keep for your records) to Tots ordinary dividends $ lb Qualified dividends $ 2a Total capital gain distr. 2c Section 1202 gain 3 NondMdend distributions 6 Foreign tax paid $ 8 Cash licsidation distributions $ 10 Exempt-interest dividends $ 12 State 13 suilegeninceionno OMB No. 1545-0110 2017 Form 1099-DIV Dividends and Distributions 2b Unrecap. Sec. 1250 gain 2d Collectibles (28%) gain $ 4 Federal mome tax withheld $ 5 Investment expenses $ 7 Foreign coutry or U.S. possession 9 Noncash irsidaticn dsubutions $ 11 Specified private activity bond interest dwidends $ 14 State tax withheld $ I Copy B For Recipient This is important tax information and is being furnished to the Internal Revenue Service. 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. www.iragovfican1099div Department of the Treason - Internal Revenue Service EFTA01222593