PDF document
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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. 
                                                                                                                   Form 1099-DIV 
                                                                            $                                                                     Dividends and 
                                                                            1b  Qualified dividends                (Rev. January 2022)                    Distributions 
                                                                                                                   For calendar year
                                                                            $                                           20
                                                                            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
                                                                                                                                                          current 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. 
                                                    11  FATCA filing        12  Exempt-interest dividends          13  Specified private activity 
                                                    requirement                                                         bond interest dividends
                                                                            $                                      $ 
Account number (see instructions)                   2nd TIN not.            14  State 15  State identification no. 16  State tax withheld
                                                                                                                   $ 
                                                                                                                   $ 
Form 1099-DIV (Rev. 1-2022)               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. 
                                                                                                                   Form 1099-DIV 
                                                                            $                                                                     Dividends and 
                                                                            1b  Qualified dividends                (Rev. January 2022)                    Distributions 
                                                                                                                   For calendar year
                                                                            $                                           20
                                                                            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
                                                                            $                                      $ 
                                                    11  FATCA filing        12  Exempt-interest dividends          13  Specified private activity 
                                                        requirement                                                     bond interest dividends
                                                                            $                                      $ 
Account number (see instructions)                                           14  State 15  State identification no. 16  State tax withheld
                                                                                                                   $ 
                                                                                                                   $ 
Form 1099-DIV (Rev. 1-2022)                         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. 
                                                                                                                   Form 1099-DIV 
                                                                            $                                                                     Dividends and 
                                                                            1b  Qualified dividends                (Rev. January 2022)                     Distributions 
                                                                                                                   For calendar year
                                                                            $                                           20
                                                                            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        12  Exempt-interest dividends          13  Specified private activity          not been reported. 
                                                    11  
                                                        requirement                                                     bond interest dividends
                                                                            $                                      $ 
Account number (see instructions)                                           14  State 15  State identification no. 16  State tax withheld
                                                                                                                   $ 
                                                                                                                   $ 
Form 1099-DIV (Rev. 1-2022)         (keep for your records)                   www.irs.gov/Form1099DIV                Department of the Treasury - Internal Revenue Service



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Instructions for Recipient                                                            indirect foreign owners or beneficiaries. It is generally treated as effectively 
Recipient’s taxpayer identification number (TIN). For your protection, this           connected to a trade or business within the United States. See the instructions 
form may show only the last four digits of your TIN (SSN, ITIN, ATIN, or EIN).        for your tax return.
However, the issuer has reported your complete TIN to the IRS.                        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 
Box 1b. Shows the portion of the amount in box 1a that may be eligible for            return as tax withheld. 
reduced capital gains rates. See the Instructions for Form 1040 for how to            Box 5. Shows the portion of the amount in box 1a that may be eligible for the 
determine this amount and where to report.                                            20% qualified business income deduction under section 199A. See the 
The amount shown may be dividends a corporation paid directly to you as a             instructions for Form 8995 and Form 8995-A.
participant (or beneficiary of a participant) in an employee stock ownership plan     Box 6. Shows your share of expenses of a nonpublicly offered RIC, generally a 
(ESOP). Report it as a dividend on your Form 1040 or 1040-SR but treat it as a        nonpublicly offered mutual fund. This amount is included in box 1a. 
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 or a 
Box 2a. Shows total capital gain distributions from a regulated investment            credit on Form 1040 or 1040-SR. See the Instructions for Form 1040. 
company (RIC) or real estate investment trust (REIT). See How To Report in the        Box 8. This box should be left blank if a RIC reported the foreign tax shown in 
Instructions for Schedule D (Form 1040). But, if no amount is shown in boxes 2b,      box 7. 
2c, 2d, and 2f and your only capital gains and losses are capital gain distributions, Boxes 9 and 10. Show cash and noncash liquidation distributions. 
you may be able to report the amounts shown in box 2a on your Form 1040 or            Box 11. If the FATCA filing requirement box is checked, the payer is reporting 
1040-SR rather than Schedule D. See the Instructions for Form 1040.                   on this Form 1099 to satisfy its account reporting requirement under chapter 4 
Box 2b. Shows the portion of the amount in box 2a that is unrecaptured section        of the Internal Revenue Code. You may also have a filing requirement. See the 
1250 gain from certain depreciable real property. See the Unrecaptured Section        Instructions for Form 8938.
1250 Gain Worksheet in the Instructions for Schedule D (Form 1040).                   Box 12. Shows exempt-interest dividends from a mutual fund or other RIC paid 
Box 2c. Shows the portion of the amount in box 2a that is section 1202 gain           to you during the calendar year. See the Instructions for Form 1040 for where to 
from certain small business stock that may be subject to an exclusion. See the        report. This amount may be subject to backup withholding. See Box 4 above.
Schedule D (Form 1040) instructions.                                                  Box 13. Shows exempt-interest dividends subject to the alternative minimum 
Box 2d. Shows the portion of the amount in box 2a that is 28% rate gain from          tax. This amount is included in box 12. See the Instructions for Form 6251.
sales or exchanges of collectibles. If required, use this amount when completing      Boxes 14–16. State income tax withheld reporting boxes.
the 28% Rate Gain Worksheet in the Instructions for Schedule D (Form 1040). 
Box 2e. Shows the portion of the amount in box 1a that is section 897 gain            Nominees. If this form includes amounts belonging to another person, you are 
attributable to disposition of U.S. real property interests (USRPI).                  considered a nominee recipient. You must file Form 1099-DIV (with a Form 
                                                                                      1096) with the IRS for each of the other owners to show their share of the 
Box 2f. Shows the portion of the amount in box 2a that is section 897 gain            income, and you must furnish a Form 1099-DIV to each. A spouse is not 
attributable to disposition of USRPI.                                                 required to file a nominee return to show amounts owned by the other spouse. 
Note: Boxes 2e and 2f apply only to foreign persons and entities whose income         See the current General Instructions for Certain Information Returns. 
maintains its character when passed through or distributed to its direct or



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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. 
                                                                                                                   Form 1099-DIV 
                                                                            $                                                                     Dividends and 
                                                                            1b  Qualified dividends                (Rev. January 2022)                    Distributions 
                                                                                                                   For calendar year
                                                                            $                                           20
                                                                            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 
                                                                            $                                      $ 
                                                    11  FATCA filing        12  Exempt-interest dividends          13  Specified private activity 
                                                        requirement                                                     bond interest dividends
                                                                            $                                      $ 
Account number (see instructions)                                           14  State 15  State identification no. 16  State tax withheld
                                                                                                                   $ 
                                                                                                                   $ 
Form 1099-DIV (Rev. 1-2022)                         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. 
                                                                                                                   Form 1099-DIV 
                                                                            $                                                                     Dividends and 
                                                                            1b  Qualified dividends                (Rev. January 2022)                    Distributions 
                                                                                                                   For calendar year
                                                                            $                                           20
                                                                            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
                                                                                                                                                          current 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. 
                                                    11  FATCA filing        12  Exempt-interest dividends          13  Specified private activity 
                                                        requirement                                                     bond interest dividends
                                                                            $                                      $ 
Account number (see instructions)                   2nd TIN not.            14  State 15  State identification no. 16  State tax withheld
                                                                                                                   $ 
                                                                                                                   $ 
Form 1099-DIV (Rev. 1-2022)                         www.irs.gov/Form1099DIV                                          Department of the Treasury - Internal Revenue Service



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Instructions for Payer 
To complete Form 1099-DIV, use:                             Foreign dividend recipient. If the recipient of the  
• The current General Instructions for Certain              dividend is a nonresident alien, you may have to 
Information Returns, and                                    withhold federal income tax and file Form 1042-S. See 
                                                            the Instructions for Form 1042-S and Pub. 515. 
• The current Instructions for Form 1099-DIV.
                                                            Need help? If you have questions about reporting on  
To order these instructions and additional forms, go        Form 1099-DIV, call the information reporting customer  
to www.irs.gov/EmployerForms.                               service site toll free at 866-455-7438 or 304-263-8700 
Caution: Because paper forms are scanned during             (not toll free). Persons with a hearing or speech 
processing, you cannot file certain Forms 1096, 1097,       disability with access to TTY/TDD equipment can call 
1098, 1099, 3921, or 5498 that you print from the IRS       304-579-4827 (not toll free).
website. 
Filing and furnishing. For filing and furnishing 
instructions, including due dates, and to request filing or 
furnishing extensions, see the current General 
Instructions for Certain Information Returns.






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