SCHEDULE B                                                                                                                      OMB No. 1545-0074
(Form 1040)                                        Interest and Ordinary Dividends
                                       ▶
Department of the Treasury               Go to www.irs.gov/ScheduleB for instructions and the latest information.               Attachment  2021
Internal Revenue Service (99)                           ▶ Attach to Form 1040 or 1040-SR.                                       Sequence No. 08 
Name(s) shown on return                                                                                                   Your social security number

Part I              1         List  name  of  payer.  If  any  interest  is  from  a  seller-financed  mortgage  and  the         Amount
                              buyer used the property as a personal residence, see the instructions and list this 
Interest                      interest first. Also, show that buyer’s social security number and address ▶
 
(See instructions 
and the 
Instructions for  
Form 1040, line 
2b.)   
 
Note: If you                                                                                                                1 
received a Form  
1099-INT, Form  
1099-OID, or  
substitute  
statement from 
a brokerage firm,  
list the firm’s  
name as the 
payer and enter  
the total interest  
shown on that  
form. 
                    2         Add the amounts on line 1 .    . . . . .   . .     . .  .   .   . .    . .  . .      .        2 
                    3         Excludable  interest  on  series  EE  and  I  U.S.  savings  bonds  issued  after  1989. 
                              Attach Form 8815 .    . . .    . . . . .   . .     . .  .   .   . .    . .  . .      .        3 
                    4         Subtract line 3 from line 2. Enter the result here and on Form 1040 or 1040-SR, 
                              line 2b  . .  .     . . . .    . . . . .   . .     . .  .   .   . .    . .  . .      ▶        4 
                    Note:  If line 4 is over $1,500, you must complete Part III.                                                  Amount 
Part II             5         List name of payer  ▶

Ordinary  
Dividends
 
(See instructions 
and the 
Instructions for 
Form 1040, line 
3b.)                                                                                                                        5 
 
Note: If you 
received a Form 
1099-DIV or 
substitute 
statement from 
a brokerage firm, 
list the firm’s 
name as the 
payer and enter 
the ordinary 
dividends shown     6         Add the amounts on line 5. Enter the total here and on Form 1040 or 1040-SR, 
on that form. 
                              line 3b  . .  .     . . . .    . . . . .   . .     . .  .   .   . .    . .  . .      ▶        6 
                    Note:  If line 6 is over $1,500, you must complete Part III. 
Part III            You must complete this part if you (a) had over $1,500 of taxable interest or ordinary dividends; (b) had a 
                    foreign account; or (c) received a distribution from, or were a grantor of, or a transferor to, a foreign trust.        Yes  No
Foreign             7 a       At any time during 2021, did you have a financial interest in or signature authority over a financial
Accounts                      account (such as a bank account, securities account, or brokerage account) located in a foreign
and Trusts                    country? See instructions  .   . . . . .   . .     . .  .   .   . .    . .  . .      .      . . . . .
 
Caution: If                   If  “Yes,”  are  you  required  to  file  FinCEN  Form  114,  Report  of  Foreign  Bank  and  Financial
required, failure             Accounts (FBAR), to report that financial interest or signature authority? See FinCEN Form 114
to file FinCEN                and its instructions for filing requirements and exceptions to those requirements  .        . . . . .
Form 114 may                  If  you  are  required  to  file  FinCEN  Form  114,  enter  the  name  of  the  foreign  country  where  the 
result in           b 
substantial                   financial account is located  ▶
penalties. See      8         During 2021, did you receive a distribution from, or were you the grantor of, or transferor to, a 
instructions.                 foreign trust? If “Yes,” you may have to file Form 3520. See instructions . . .      .      . . . . .
For Paperwork Reduction Act Notice, see your tax return instructions.                 Cat. No. 17146N                     Schedule B (Form 1040) 2021