7373                           VOID              CORRECTED
CORPORATION’S name, street address, city or town, state or province,     1   Date of sale or exchange OMB No. 1545-1814
country, ZIP or foreign postal code, and telephone no.
                                                                                                      Form 1099-CAP                 Changes in 
                                                                                                                                    Corporate 
                                                                         2   Aggregate amount rec’d*  (Rev. September 2019)         Control and 
                                                                                                       For calendar year       Capital Structure
                                                                         $                                 20
CORPORATION’S TIN                   SHAREHOLDER’S TIN                    3   No. of shares exchanged  4  Classes of stock exchanged Copy A
                                                                                                                                    For 
SHAREHOLDER’S name                                                                                                                  Internal Revenue 
                                                                                                                                    Service Center
                                                                                                                                    File with Form 1096. 
Street address (including apt. no.)                                                                                                 For Paperwork 
                                                                         5                                                          Reduction Act 
                                                                                                                                    Notice, see the 
City or town, state or province, country, and ZIP or foreign postal code                                                            current General 
                                                                                                                                    Instructions for 
Account number (see instructions)                                          * The shareholder cannot claim a loss based on the       Certain Information 
                                                                           amount in box 2.                                         Returns.
Form 1099-CAP (Rev. 9-2019)         Cat. No. 35115M                      www.irs.gov/Form1099CAP       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

                                                      CORRECTED (if checked)
CORPORATION’S name, street address, city or town, state or province,     1   Date of sale or exchange OMB No. 1545-1814
country, ZIP or foreign postal code, and telephone no.
                                                                                                      Form 1099-CAP                 Changes in 
                                                                                                                                    Corporate 
                                                                         2   Aggregate amount rec’d*  (Rev. September 2019)         Control and 
                                                                                                       For calendar year     Capital Structure
                                                                         $                                 20
CORPORATION’S TIN                   SHAREHOLDER’S TIN                    3   No. of shares exchanged  4  Classes of stock exchanged Copy B
                                                                                                                                    For Shareholder
SHAREHOLDER’S name                                                                                                                  This is important tax 
                                                                                                                                    information and is being 
                                                                                                                                    furnished to the IRS. If 
                                                                                                                                    you are required to file a 
Street address (including apt. no.)                                                                                                 return, a negligence 
                                                                                                                                    penalty or other 
                                                                         5                                                          sanction may be 
City or town, state or province, country, and ZIP or foreign postal code                                                            imposed on you if 
                                                                                                                                    taxable income results 
                                                                                                                                    from this transaction 
Account number (see instructions)                                                                                                   and the IRS determines 
                                                                           * You cannot claim a loss based on the amount in box 2.  that it has not been 
                                                                                                                                    reported.
Form 1099-CAP (Rev. 9-2019)         (keep for your records)              www.irs.gov/Form1099CAP       Department of the Treasury - Internal Revenue Service

Instructions for Shareholder
A corporation in which you own stock that has had a        Account number. May show an account or other 
change in control or a substantial change in capital       unique number the payer corporation assigned to 
structure must send you this statement by January 31 of    distinguish your account.
the year following the calendar year of the change. You    Box 1. Shows the date the stock was exchanged for 
have received this statement because the corporation       cash, stock, or other property.
has reasonably determined that you may be required to      Box 2. Shows the aggregate amount of any cash and 
recognize gain from the receipt of cash, stock, or other   the fair market value of any stock or other property 
property that was exchanged for the corporation’s          received by you in the exchange for the stock you held.
stock. Report any gain from the exchange on Form 
8949. However, you cannot claim a (loss) on Form 8949      Box 3. Shows the number of shares of the corporation’s 
as a result of this exchange. See chapter 4 of Pub. 550    stock that you held which were exchanged in the 
for additional information.                                transaction.
Shareholder’s taxpayer identification number (TIN).        Box 4. Shows the class or classes of stock that were 
For your protection, this form may show only the last      exchanged.
four digits of your TIN (social security number (SSN),     Future developments. For the latest information about 
individual taxpayer identification number (ITIN), adoption developments related to Form 1099-CAP and its 
taxpayer identification number (ATIN), or employer         instructions, such as legislation enacted after they were 
identification number (EIN)). However, the issuer has      published, go to www.irs.gov/Form1099CAP.
reported your complete TIN to the IRS.

                                    VOID              CORRECTED
CORPORATION’S name, street address, city or town, state or province,     1   Date of sale or exchange OMB No. 1545-1814
country, ZIP or foreign postal code, and telephone no.
                                                                                                      Form 1099-CAP                Changes in 
                                                                                                                                   Corporate 
                                                                         2   Aggregate amount rec’d*  (Rev. September 2019)        Control and 
                                                                                                       For calendar year       Capital Structure
                                                                         $                                 20
CORPORATION’S TIN                   SHAREHOLDER’S TIN                    3   No. of shares exchanged  4  Classes of stock exchanged
                                                                                                                                   Copy C
SHAREHOLDER’S name                                                                                                                 For Corporation
                                                                                                                                   For Paperwork 
                                                                                                                                   Reduction Act 
Street address (including apt. no.)                                                                                                Notice, see the 
                                                                         5                                                         current General 
City or town, state or province, country, and ZIP or foreign postal code                                                           Instructions for 
                                                                                                                                   Certain Information 
                                                                                                                                   Returns.
Account number (see instructions)                                          * The shareholder cannot claim a loss based on the  
                                                                           amount in box 2.
Form 1099-CAP (Rev. 9-2019)                           www.irs.gov/Form1099CAP                          Department of the Treasury - Internal Revenue Service

Instructions for Corporation
To complete Form 1099-CAP, use:                             To file electronically, you must have software that 
• The current General Instructions for Certain              generates a file according to the specifications in Pub. 
Information Returns, and                                    1220.
• The current Instructions for Form 1099-CAP.               Need help? If you have questions about reporting on 
To get or to order these instructions, go to                Form 1099-CAP, call the information reporting customer 
www.irs.gov/Form1099CAP.                                    service site toll free at 866-455-7438 or 304-263-8700 
                                                            (not toll free). Persons with a hearing or speech 
Filing and furnishing. For filing and furnishing 
                                                            disability with access to TTY/TDD equipment can call 
instructions, including due dates, and to request filing or 
                                                            304-579-4827 (not toll free). 
furnishing extensions, see the current General 
Instructions for Certain Information Returns.