CORRECTED if checked PAYER'S wne. street city bun, state or province, contry. ZIP or postal code, and telephom no. AT&T 2 Call Lane Your City, Your State Your Zip PAYER' S Federal identific*ion RECIPIENTS identifzation nunu 54-1658683 RECIPIENTS Dianne Duncan Street address (Guding apt m.) 910 Riverline Drive 306-00-1212 City crtcmn, sta or movince, county , ZIP or foreign Your City, Your State Your Zip Acmunt nun ber (see instructions) Ia Total &vidends $ 256.00 lb 'vidends 2a Total capibl gain distr. 2c Section 1202 gai 3 Nmfvidend digribubons 6 hx paid 8 Cash liquidation distrbtions 10 Exengt-iterest divimis '2 State 13 SOE 1545-0110 20xx Form 1099-DIV 2b Unrecap Sec. gain 2d CalZb&s (28%) gain 4 Federal ireome wiNId 5 Investment exmses 9 Noncash liquid ako distributions I Sgefied private XEvity bond Orest &vidends Dividends and Distributions copy B For Recipient This tax furnihd to Internal If ym are fie a return. a Ot"r the RS hat has not FATCA 1099-DIV (keep for your records) www.irs/form1099div Department of the Treasury Internal Revenue Service