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                                    Attention: 

Copy A of this form is provided for informational purposes only. Copy A appears in red, 
similar to the official IRS form. The official printed version of Copy A of this IRS form is 
scannable, but the online version of it, printed from this website, is not. Do not print and file 
copy A downloaded from this website; a penalty may be imposed for filing with the IRS 
information return forms that can’t be scanned. See part O in the current General 
Instructions for Certain Information Returns, available at www.irs.gov/form1099, for more 
information about penalties.

Please note that Copy B and other copies of this form, which appear in black, may be 
downloaded and printed and used to satisfy the requirement to provide the information to 
the recipient.

To order official IRS information returns, which include a scannable Copy A for filing with 
the IRS and all other applicable copies of the form, visit www.IRS.gov/orderforms. Click on 
Employer and Information Returns, and we’ll mail you the forms you request and their 
instructions, as well as any publications you may order.

Information returns may also be filed electronically using the IRS Filing Information Returns 
Electronically (FIRE) system (visit www.IRS.gov/FIRE) or the IRS Affordable Care Act 
Information Returns (AIR) program (visit www.IRS.gov/AIR).

See IRS Publications 1141, 1167, and 1179 for more information about printing these tax 
forms.



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              9191                        VOID      CORRECTED
PAYER’S name, street address, city or town, state or province, country, ZIP 1a  Total ordinary dividends           OMB No. 1545-0110 
or foreign postal code, and telephone no. 
                                                                            $                                                                     Dividends and 
                                                                            1b  Qualified dividends                2021                                   Distributions 

                                                                            $                                      Form  1099-DIV 
                                                                            2a  Total capital gain distr.          2b  Unrecap. Sec. 1250 gain            Copy A
                                                                            $                                      $                                      For 
PAYER’S TIN                         RECIPIENT’S TIN                         2c  Section 1202 gain                  2d  Collectibles (28%) gain            Internal Revenue 
                                                                            $                                      $                                      Service Center 
                                                                            2e  Section 897 ordinary dividends     2f  Section 897 capital gain 
                                                                                                                                                          File with Form 1096.
                                                                            $                                      $ 
RECIPIENT’S name                                                            3    Nondividend distributions         4    Federal income tax withheld 
                                                                            $                                      $                                      For Privacy Act 
                                                                            5    Section 199A dividends            6    Investment expenses               and Paperwork 
Street address (including apt. no.)                                         $                                      $                                      Reduction Act 
                                                                                                                                                          Notice, see the 
                                                                            7    Foreign tax paid                  8    Foreign country or U.S. possession
                                                                                                                                                          2021 General 
                                                                                                                                                          Instructions for 
City or town, state or province, country, and ZIP or foreign postal code    $                                                                             Certain 
                                                                            9    Cash liquidation distributions    10   Noncash liquidation distributions Information 
                                                                            $                                      $                                      Returns. 
                                                    FATCA filing            11  Exempt-interest dividends          12  Specified private activity 
                                                    requirement                                                         bond interest dividends
                                                                            $                                      $ 
Account number (see instructions)                   2nd TIN not.            13  State 14  State identification no. 15  State tax withheld
                                                                                                                   $ 
                                                                                                                   $ 
Form 1099-DIV                       Cat. No. 14415N                           www.irs.gov/Form1099DIV              Department of the Treasury - Internal Revenue Service
Do  Not  Cut  or  Separate  Forms  on  This  Page    —     Do  Not  Cut  or  Separate  Forms  on  This  Page



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                                          VOID      CORRECTED
PAYER’S name, street address, city or town, state or province, country, ZIP 1a  Total ordinary dividends           OMB No. 1545-0110 
or foreign postal code, and telephone no. 
                                                                            $                                                                     Dividends and 
                                                                            1b  Qualified dividends                  2021                                 Distributions 

                                                                            $                                      Form  1099-DIV 
                                                                            2a  Total capital gain distr.          2b  Unrecap. Sec. 1250 gain            Copy 1
                                                                            $                                      $                                      For State Tax 
PAYER’S TIN                         RECIPIENT’S TIN                         2c  Section 1202 gain                  2d  Collectibles (28%) gain            Department 
                                                                            $                                      $ 
                                                                            2e  Section 897 ordinary dividends     2f  Section 897 capital gain 
                                                                            $                                      $ 
RECIPIENT’S name                                                            3    Nondividend distributions         4    Federal income tax withheld 
                                                                            $                                      $ 
                                                                            5    Section 199A dividends            6    Investment expenses 
Street address (including apt. no.)                                         $                                      $ 
                                                                            7    Foreign tax paid                  8    Foreign country or U.S. possession

City or town, state or province, country, and ZIP or foreign postal code    $ 
                                                                            9    Cash liquidation distributions    10   Noncash liquidation distributions
                                                                            $                                      $ 
                                                    FATCA filing            11  Exempt-interest dividends          12  Specified private activity 
                                                    requirement                                                         bond interest dividends
                                                                            $                                      $ 
Account number (see instructions)                                           13  State 14  State identification no. 15  State tax withheld
                                                                                                                   $ 
                                                                                                                   $ 
Form 1099-DIV                                       www.irs.gov/Form1099DIV                                          Department of the Treasury - Internal Revenue Service



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                                                    CORRECTED (if checked)
PAYER’S name, street address, city or town, state or province, country, ZIP 1a  Total ordinary dividends           OMB No. 1545-0110 
or foreign postal code, and telephone no. 
                                                                            $                                                                     Dividends and 
                                                                            1b  Qualified dividends                  2021                                  Distributions 

                                                                            $                                      Form  1099-DIV 
                                                                            2a  Total capital gain distr.          2b  Unrecap. Sec. 1250 gain             Copy B 
                                                                            $                                      $ 
PAYER’S TIN                         RECIPIENT’S TIN                         2c  Section 1202 gain                  2d  Collectibles (28%) gain             For Recipient 
                                                                            $                                      $ 
                                                                            2e  Section 897 ordinary dividends     2f  Section 897 capital gain 
                                                                            $                                      $ 
RECIPIENT’S name                                                            3    Nondividend distributions         4    Federal income tax withheld 
                                                                                                                                                           This is important tax 
                                                                            $                                      $                                       information and is 
                                                                            5    Section 199A dividends            6    Investment expenses                being furnished to 
Street address (including apt. no.)                                         $                                      $                                       the IRS. If you are 
                                                                                                                                                           required to file a 
                                                                            7    Foreign tax paid                  8    Foreign country or U.S. possession return, a negligence 
                                                                                                                                                           penalty or other 
                                                                                                                                                           sanction may be 
City or town, state or province, country, and ZIP or foreign postal code    $                                                                              imposed on you if 
                                                                                 Cash liquidation distributions    10   Noncash liquidation distributions   this income is taxable 
                                                                            9                                                                              and the IRS 
                                                                            $                                      $                                       determines that it has 
                                                    FATCA filing            11  Exempt-interest dividends          12  Specified private activity          not been reported. 
                                                    requirement                                                         bond interest dividends
                                                                            $                                      $ 
Account number (see instructions)                                           13  State 14  State identification no. 15  State tax withheld
                                                                                                                   $ 
                                                                                                                   $ 
Form 1099-DIV    (keep for your records)                                      www.irs.gov/Form1099DIV                Department of the Treasury - Internal Revenue Service



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Instructions for Recipient                                                        Box 2f. Shows the portion of the amount in box 2a that is section 897 gain 
Recipient’s taxpayer identification number (TIN). For your protection, this       attributable to disposition of USRPI.
form may show only the last four digits of your TIN (SSN, ITIN, ATIN, or EIN).    Note: Boxes 2e and 2f apply only to foreign persons and entities whose income 
However, the issuer has reported your complete TIN to the IRS.                    maintains its character when passed through or distributed to its direct or 
FATCA filing requirement. If the FATCA filing requirement box is checked, the     indirect foreign owners or beneficiaries. It is generally treated as effectively 
payer is reporting on this Form 1099 to satisfy its account reporting requirement connected to a trade or business within the United States. See the instructions 
under chapter 4 of the Internal Revenue Code. You may also have a filing          for your tax return.
requirement. See the Instructions for Form 8938.                                  Box 3. Shows a return of capital. To the extent of your cost (or other basis) in 
Account number. May show an account or other unique number the payer              the stock, the distribution reduces your basis and is not taxable. Any amount 
assigned to distinguish your account.                                             received in excess of your basis is taxable to you as capital gain. See Pub. 550.
Box 1a. Shows total ordinary dividends that are taxable. Include this amount on   Box 4. Shows backup withholding. A payer must backup withhold on certain 
the “Ordinary dividends” line of Form 1040 or 1040-SR. Also report it on          payments if you did not give your TIN to the payer. See Form W-9  for 
Schedule B (Form 1040), if required.                                              information on backup withholding. Include this amount on your income tax 
                                                                                  return as tax withheld. 
Box 1b. Shows the portion of the amount in box 1a that may be eligible for        Box 5. Shows the portion of the amount in box 1a that may be eligible for the 
reduced capital gains rates. See the Instructions for Forms 1040 and 1040-SR      20% qualified business income deduction under section 199A. See the 
for how to determine this amount and where to report.                             instructions for Form 8995 and Form 8995-A.
The amount shown may be dividends a corporation paid directly to you as a         Box 6. Shows your share of expenses of a nonpublicly offered RIC, generally a 
participant (or beneficiary of a participant) in an employee stock ownership plan nonpublicly offered mutual fund. This amount is included inbox 1a. 
(ESOP). Report it as a dividend on your Form 1040 or 1040-SR but treat it as a 
plan distribution, not as investment income, for any other purpose.               Box 7. Shows the foreign tax that you may be able to claim as a deduction ora 
Box 2a. Shows total capital gain distributions from a regulated investment        credit on Form 1040 or 1040-SR. See the Instructions for Forms 1040 and 1040-
company (RIC) or real estate investment trust (REIT). See How To Report in the    SR. 
Instructions for Schedule D (Form 1040). But, if no amount is shown in boxes      Box 8. This box should be left blank if a RIC reported the foreign tax shown in 
2b, 2c, 2d, and 2f and your only capital gains and losses are capital gain        box 7. 
distributions, youmay  be able to report the amounts shown in box 2a on your      Boxes 9 and 10. Show cash and noncash liquidation distributions. 
Form 1040 or 1040-SR rather than Schedule D. See the Instructions for Forms       Box 11. Shows exempt-interest dividends from a mutual fund or other RIC paid 
1040 and 1040-SR.                                                                 to you during the calendar year. See the Instructions for Forms 1040 and 1040-
Box 2b. Shows the portion of the amount in box 2a that is unrecaptured section    SR for where to report. This amount may be subject to backup withholding. See 
1250 gain from certain depreciable real property. See the Unrecaptured Section    Box 4 above.
1250 Gain Worksheet in the Instructions for Schedule D (Form 1040).               Box 12. Shows exempt-interest dividends subject to the alternative minimum 
Box 2c. Shows the portion of the amount in box 2a that is section 1202 gain       tax. This amount is included in box 11. See the Instructions for Form 6251.
from certain small business stock that may be subject to an exclusion. See the    Boxes 13–15. State income tax withheld reporting boxes.
Schedule D (Form 1040) instructions.                                              Nominees. If this form includes amounts belonging to another person, you are 
Box 2d. Shows the portion of the amount in box 2a that is 28% rate gain from      considered a nominee recipient. You must file Form 1099-DIV (with a Form 
sales or exchanges of collectibles. If required, use this amount when completing  1096) with the IRS for each of the other owners to show their share of the 
the 28% Rate Gain Worksheet in the Instructions for Schedule D (Form 1040).       income, and you must furnish a Form 1099-DIV to each. A spouse is not 
Box 2e. Shows the portion of the amount in box 1a that is section 897 gain        required to file a nominee return to show amounts owned by the other spouse. 
attributable to disposition of U.S. real property interests (USRPI).              See the 2021 GeneralInstructions for Certain Information Returns. 



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                                          VOID      CORRECTED
PAYER’S name, street address, city or town, state or province, country, ZIP 1a  Total ordinary dividends           OMB No. 1545-0110 
or foreign postal code, and telephone no. 
                                                                            $                                                                     Dividends and 
                                                                            1b  Qualified dividends                  2021                                 Distributions 

                                                                            $                                      Form  1099-DIV 
                                                                            2a  Total capital gain distr.          2b  Unrecap. Sec. 1250 gain            Copy 2
                                                                            $                                      $ 
PAYER’S TIN                         RECIPIENT’S TIN                         2c  Section 1202 gain                  2d  Collectibles (28%) gain            To be filed with 
                                                                                                                                                          recipient’s state 
                                                                            $                                      $                                      income tax return, 
                                                                            2e  Section 897 ordinary dividends     2f  Section 897 capital gain           when required.
                                                                            $                                      $ 
RECIPIENT’S name                                                            3    Nondividend distributions         4    Federal income tax withheld
                                                                            $                                      $ 
                                                                            5    Section 199A dividends            6    Investment expenses 
Street address (including apt. no.)                                         $                                      $ 
                                                                            7    Foreign tax paid                  8    Foreign country or U.S. possession

City or town, state or province, country, and ZIP or foreign postal code    $ 
                                                                            9    Cash liquidation distributions    10   Noncash liquidation distributions 
                                                                            $                                      $ 
                                                    FATCA filing            11  Exempt-interest dividends          12  Specified private activity 
                                                    requirement                                                         bond interest dividends
                                                                            $                                      $ 
Account number (see instructions)                                           13  State 14  State identification no. 15  State tax withheld
                                                                                                                   $ 
                                                                                                                   $ 
Form 1099-DIV                                       www.irs.gov/Form1099DIV                                          Department of the Treasury - Internal Revenue Service



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                                          VOID      CORRECTED
PAYER’S name, street address, city or town, state or province, country, ZIP 1a  Total ordinary dividends           OMB No. 1545-0110 
or foreign postal code, and telephone no. 
                                                                            $                                                                     Dividends and 
                                                                            1b  Qualified dividends                  2021                                 Distributions 

                                                                            $                                      Form  1099-DIV 
                                                                            2a  Total capital gain distr.          2b  Unrecap. Sec. 1250 gain            Copy C
                                                                            $                                      $                                      For Payer
PAYER’S TIN                         RECIPIENT’S TIN                         2c  Section 1202 gain                  2d  Collectibles (28%) gain 
                                                                            $                                      $ 
                                                                            2e  Section 897 ordinary dividends     2f  Section 897 capital gain 
                                                                            $                                      $ 
RECIPIENT’S name                                                            3    Nondividend distributions         4    Federal income tax withheld
                                                                            $                                      $                                      For Privacy Act 
                                                                            5    Section 199A dividends            6    Investment expenses               and Paperwork 
Street address (including apt. no.)                                         $                                      $                                      Reduction Act 
                                                                                                                                                          Notice, see the 
                                                                            7    Foreign tax paid                  8    Foreign country or U.S. possession
                                                                                                                                                          2021 General 
                                                                                                                                                          Instructions for 
City or town, state or province, country, and ZIP or foreign postal code    $                                                                             Certain 
                                                                            9    Cash liquidation distributions    10   Noncash liquidation distributions Information 
                                                                            $                                      $                                      Returns. 
                                                    FATCA filing            11  Exempt-interest dividends          12  Specified private activity 
                                                    requirement                                                         bond interest dividends
                                                                            $                                      $ 
Account number (see instructions)                   2nd TIN not.            13  State 14  State identification no. 15  State tax withheld
                                                                                                                   $ 
                                                                                                                   $ 
Form 1099-DIV                                       www.irs.gov/Form1099DIV                                          Department of the Treasury - Internal Revenue Service



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Instructions for Payer 
To complete Form 1099-DIV, use:                          software that generates a file according to the  
                                                         specifications in Pub. 1220. The IRS does not provide a 
• The 2021 General Instructions for Certain Information  fill-in form option for Copy A. 
Returns, and
                                                         Foreign dividend recipient. If the recipient of the  
• The 2021 Instructions for Form 1099-DIV.               dividend is a nonresident alien, you may have to 
To order these instructions and additional forms, go     withhold federal income tax and file Form 1042-S. See 
to www.irs.gov/Form1099DIV.                              the Instructions for Form 1042-S and Pub. 515. 
Caution: Because paper forms are scanned during          Need help? If you have questions about reporting on  
processing, you cannot file Forms 1096, 1097,1098,       Form 1099-DIV, call the information reporting customer  
1099, 3921, or 5498 that you print from the IRS website. service site toll free at 866-455-7438 or 304-263-8700 
Due dates. Furnish Copy B of this form to the recipient  (not toll free). Persons with a hearing or speech 
by January 31, 2022.                                     disability with access to TTY/TDD equipment can call 
                                                         304-579-4827 (not toll free).
File Copy A of this form with the IRS by February 28, 
2022. If you file electronically, the due date is  
March 31, 2022. To file electronically, you must have 






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