CORRECTED (if checked) FAYER'S name, street address, city or town state or province country, ZIP | 18 Total ordinary dividends OME No. 1545-01 10 or foreign postal code, and telephone no. DALBEY CORPORATION 16 Qualfied 300 0 0 2019 Dividends and Distributions WASHINGTON & 3rd STS SPRINGFIELD, IL 62701 3000 - Form 1099-DIV 2a Total capital gain disto 2b Untocap. Sec. 1250 gain Copy B PAYER'S federal identification number RECIPIENT'S identification number 2c Section 1202 pain 2d Collectibles (2896) gain For Recipient 76-3451789 448-56-2303 RECIPIENT'S name 3 Nondividend distributions 4 Federal income tax withheld This is important tax GEORGE AND NILA AMBERSON information and it 5 Investment expenses being furnished to Street address (including apt co.) the Intemal Revenue Service. I you are 315 WEST AVE 6 Foreign tax paid 7 Foreign country or U.S. possession requires to like a return, a negligence penalty of other Chy of town, state or province, country, and ZIP or foreign postal code sanction may be imposed on you if TEMPLE, TX 76501 8 Cash liquidation distributions 9 Noncash liquidation distributions this income is taxable and the IRS FATCA filing 10 Exempt-interesi dividends 11 Specified private activity determines that it has requirement bond interest dividendr not been repoand. Account number isse instructions) 12 State | 13 Swi idenvestior no 14 State lax withhold Form 1099-DIV (keep for your records) www.irs.gov/for1089:N Department of the Treasury Internal Revenue Service 1099 - Div