Fillable Printable Form 1099-DIV
Fillable Printable Form 1099-DIV
Form 1099-DIV
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.
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Information returns may also be filed electronically using the IRS Filing Information Returns
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) or the IRS Affordable Care Act
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See IRS Publications 1141, 1167, and 1179 for more information about printing these tax
forms.
Form 1099-DIV
2017
Cat. No. 14415N
Dividends and
Distributions
Copy A
For
Internal Revenue
Service Center
Department of the Treasury - Internal Revenue Service
File with Form 1096.
OMB No. 1545-0110
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2017 General
Instructions for
Certain
Information
Returns.
9191
VOID CORRECTED
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 (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
FATCA filing
requirement
Account number (see instructions)
2nd TIN not.
1a Total ordinary dividends
$
1b Qualified dividends
$
2a Total capital gain distr.
$
2b Unrecap. Sec. 1250 gain
$
2c Section 1202 gain
$
2d Collectibles (28%) gain
$
3 Nondividend distributions
$
4
Federal income tax withheld
$
5 Investment expenses
$
6 Foreign tax paid
$
7 Foreign country or U.S. possession
8 Cash liquidation distributions
$
9
Noncash liquidation distributions
$
10 Exempt-interest dividends
$
11
Specified private activity
bond interest dividends
$
12 State 13
State identification no.
14 State tax withheld
$
$
Form 1099-DIV
www.irs.gov/form1099div
Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page
Form 1099-DIV
2017
Dividends and
Distributions
Copy 1
For State Tax
Department
Department of the Treasury - Internal Revenue Service
OMB No. 1545-0110
VOID CORRECTED
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 (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
FATCA filing
requirement
Account number (see instructions)
1a Total ordinary dividends
$
1b Qualified dividends
$
2a Total capital gain distr.
$
2b Unrecap. Sec. 1250 gain
$
2c Section 1202 gain
$
2d Collectibles (28%) gain
$
3 Nondividend distributions
$
4
Federal income tax withheld
$
5 Investment expenses
$
6 Foreign tax paid
$
7 Foreign country or U.S. possession
8 Cash liquidation distributions
$
9
Noncash liquidation distributions
$
10 Exempt-interest dividends
$
11
Specified private activity
bond interest dividends
$
12 State 13
State identification no.
14 State tax withheld
$
$
Form 1099-DIV
www.irs.gov/form1099div
Form 1099-DIV
2017
Dividends and
Distributions
Copy B
For Recipient
Department of the Treasury - Internal Revenue Service
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.
OMB No. 1545-0110
CORRECTED (if checked)
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 (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
FATCA filing
requirement
Account number (see instructions)
1a Total ordinary dividends
$
1b Qualified dividends
$
2a Total capital gain distr.
$
2b Unrecap. Sec. 1250 gain
$
2c Section 1202 gain
$
2d Collectibles (28%) gain
$
3 Nondividend distributions
$
4
Federal income tax withheld
$
5 Investment expenses
$
6 Foreign tax paid
$
7 Foreign country or U.S. possession
8 Cash liquidation distributions
$
9
Noncash liquidation distributions
$
10 Exempt-interest dividends
$
11
Specified private activity
bond interest dividends
$
12 State 13
State identification no.
14 State tax withheld
$
$
Form 1099-DIV
(keep for your records)
www.irs.gov/form1099div
Instructions for Recipient
Recipient's taxpayer identification number. For your protection, this form may
show only the last four digits of your social security number (SSN), individual
taxpayer identification number (ITIN), adoption taxpayer identification number
(ATIN), or employer identification number (EIN). However, the issuer has
reported your complete identification number to the IRS.
FATCA filing requirement. If the FATCA filing requirement box is checked, the
payer is reporting on this Form 1099 to satisfy its chapter 4 account reporting
requirement. You also may have a filing requirement. See the Instructions for
Form 8938.
Account number. May show an account or other unique number the payer
assigned to distinguish your account.
Box 1a. Shows total ordinary dividends that are taxable. Include this amount on
line 9a of Form 1040 or 1040A. Also, report it on Schedule B (1040A or 1040), if
required.
Box 1b. Shows the portion of the amount in box 1a that may be eligible for
reduced capital gains rates. See Form 1040/1040A instructions for how to
determine this amount. Report the eligible amount on line 9b, Form 1040 or
1040A.
The amount shown may be dividends a corporation paid directly to you as a
participant (or beneficiary of a participant) in an employee stock ownership plan
(ESOP). Report it as a dividend on your Form 1040/1040A but treat it as a plan
distribution, not as investment income, for any other purpose.
Box 2a. Shows total capital gain distributions from a regulated investment
company or real estate investment trust. Report the amounts shown in box 2a
on Schedule D (Form 1040), line 13. But, if no amount is shown in boxes 2c–2d
and your only capital gains and losses are capital gain distributions, you may be
able to report the amounts shown in box 2a on line 13 of Form 1040 (line 10 of
Form 1040A) rather than Schedule D. See the Form 1040/1040A instructions.
Box 2b. Shows the portion of the amount in box 2a that is unrecaptured section
1250 gain from certain depreciable real property. Report this amount on the
Unrecaptured Section 1250 Gain Worksheet—Line 19 in the Schedule D
instructions (Form 1040).
Box 2c. Shows the portion of the amount in box 2a that is section 1202 gain
from certain small business stock that may be subject to an exclusion. See the
Schedule D (Form 1040) instructions.
Box 2d. Shows 28% rate gain from sales or exchanges of collectibles. If
required, use this amount when completing the 28% Rate Gain Worksheet—
Line 18 in the instructions for Schedule D (Form 1040).
Box 3. Shows the part of the distribution that is nontaxable because it is a return
of your cost (or other basis). You must reduce your cost (or other basis) by this
amount for figuring gain or loss when you sell your stock. But if you get back all
your cost (or other basis), report future distributions as capital gains. See Pub.
550.
Box 4. Shows backup withholding. A payer must backup withhold on certain
payments if you did not give your taxpayer identification number to the payer.
See Form W-9, Request for Taxpayer Identification Number and Certification, for
information on backup withholding. Include this amount on your income tax
return as tax withheld.
Box 5. Shows your share of expenses of a nonpublicly offered regulated
investment company, generally a nonpublicly offered mutual fund. If you file
Form 1040, you may deduct these expenses on the “Other expenses” line on
Schedule A (Form 1040) subject to the 2% limit. This amount is included in
box 1a.
Box 6. Shows the foreign tax that you may be able to claim as a deduction or a
credit on Form 1040. See the Form 1040 instructions.
Box 7. This box should be left blank if a regulated investment company reported
the foreign tax shown in box 6.
Boxes 8 and 9. Shows cash and noncash liquidation distributions.
Box 10. Shows exempt-interest dividends from a mutual fund or other regulated
investment company paid to you during the calendar year. Include this amount
on line 8b of Form 1040 or 1040A as tax-exempt interest. This amount may be
subject to backup withholding. See box 4.
Box 11. Shows exempt-interest dividends subject to the alternative minimum
tax. This amount is included in box 10. See the Instructions for Form 6251.
Boxes 12–14. State income tax withheld reporting boxes.
Nominees. If this form includes amounts belonging to another person, you are
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
income, and you must furnish a Form 1099-DIV to each. A spouse is not
required to file a nominee return to show amounts owned by the other spouse.
See the 2017 General Instructions for Certain Information Returns.
Future developments. For the latest information about the developments
related to Form 1099-DIV and its instructions, such as legislation enacted after
they were published, go to www.irs.gov/form1099div.
Form 1099-DIV
2017
Dividends and
Distributions
Copy 2
To be filed with
recipient's state
income tax return,
when required.
Department of the Treasury - Internal Revenue Service
OMB No. 1545-0110
VOID CORRECTED
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 (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
FATCA filing
requirement
Account number (see instructions)
1a Total ordinary dividends
$
1b Qualified dividends
$
2a Total capital gain distr.
$
2b Unrecap. Sec. 1250 gain
$
2c Section 1202 gain
$
2d Collectibles (28%) gain
$
3 Nondividend distributions
$
4
Federal income tax withheld
$
5 Investment expenses
$
6 Foreign tax paid
$
7 Foreign country or U.S. possession
8 Cash liquidation distributions
$
9
Noncash liquidation distributions
$
10 Exempt-interest dividends
$
11
Specified private activity
bond interest dividends
$
12 State 13
State identification no.
14 State tax withheld
$
$
Form 1099-DIV
www.irs.gov/form1099div
Form 1099-DIV
2017
Dividends and
Distributions
Copy C
For Payer
Department of the Treasury - Internal Revenue Service
OMB No. 1545-0110
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2017 General
Instructions for
Certain
Information
Returns.
VOID CORRECTED
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 (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
FATCA filing
requirement
Account number (see instructions) 2nd TIN not.
1a Total ordinary dividends
$
1b Qualified dividends
$
2a Total capital gain distr.
$
2b Unrecap. Sec. 1250 gain
$
2c Section 1202 gain
$
2d Collectibles (28%) gain
$
3 Nondividend distributions
$
4
Federal income tax withheld
$
5 Investment expenses
$
6 Foreign tax paid
$
7 Foreign country or U.S. possession
8 Cash liquidation distributions
$
9
Noncash liquidation distributions
$
10 Exempt-interest dividends
$
11
Specified private activity
bond interest dividends
$
12 State 13
State identification no.
14 State tax withheld
$
$
Form 1099-DIV
www.irs.gov/form1099div
Instructions for Payer
To complete Form 1099-DIV, use:
• the 2017 General Instructions for Certain Information
Returns, and
• the 2017 Instructions for Form 1099-DIV.
To order these instructions and additional forms, go
to www.irs.gov/form1099div.
Caution: Because paper forms are scanned during
processing, you cannot file Forms 1096, 1097, 1098,
1099, 3921, 3922, or 5498 that you print from the IRS
website.
Due dates. Furnish Copy B of this form to the recipient
by January 31, 2018.
File Copy A of this form with the IRS by February 28,
2018. If you file electronically, the due date is
April 2, 2018. To file electronically, you must have
software that generates a file according to the
specifications in Pub. 1220. The IRS does not provide a
fill-in form option.
Foreign dividend recipient. If the recipient of the
dividend is a nonresident alien, you may have to
withhold federal income tax and file Form 1042-S. See
the Instructions for Form 1042-S and Pub. 515.
Need help? If you have questions about reporting on
Form 1099-DIV, call the information reporting customer
service site toll free at 1-866-455-7438 or 304-263-8700
(not toll free). Persons with a hearing or speech
disability with access to TTY/TDD equipment can call
304-579-4827 (not toll free).
