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OMB No. 1545-0110 2020 Dividends and Distributions 9191 VOID CORRECTED PAYER'S name, street address, city or town, state or province, country, ZIP 1a Total ordinary dividends or foreign postal code, and telephone no. $ 3674.36 LA Investment Company 1b Qualified dividends 5 Lake Avenue 145.96 Pasadena, CA 91106 $ 2a Total capital gain distr. $ 622.78 PAYER'S federal identification number RECIPIENT'S identification number 2c Section 1202 gain 90-0077001 500-00-1000 Form 1099-DIV 2b Unrecap. Sec. 1250 gain $ 2d Collectibles (28%) gain Copy A For Internal Revenue Service Center File with Form 1096. $ RECIPIENT'S name $ 3 Nondividend distributions $ Marc Pennyworth 4 Federal income tax withheld $ 5 Investment expenses $ 7 Foreign country or U.S. possession Street address (including apt. no.) 6 Foreign tax paid 100 Major Street Apt 408 City or town, state or province, country, and ZIP or foreign postal code Pasadena, CA 91106 For Privacy Act and Paperwork Reduction Act Notice, see the General Instructions for Certain Information Returns. 8 Cash liquidation distributions $ 10 Exempt-interest dividends 9 Noncash liquidation distributions $ 11 Specified private activity bond interest dividends $ $ Account number (see instructions) 2nd TIN not. 12 State 13 State identification no. 14 State tax withheld $ $ Form 1099-DIV Cat. No. 14415N www.lrs.gov/form1099div 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 Details: Dividend Income (1099-DIV) LA Investment Compan... PRIOR YEAR AMOUNT Taxpayer Spouse Joint Dividend Income (1a) Total ordinary dividends 3,674 (1b) Qualified dividends 146 (2a) Total capital gain distributions 623 (2b) Unrecaptured section 1250 gain (2c) Section 1202 gain (2d) Collectibles (28%) rate gain Details: Dividend Income (1099-DIV) LA Investment Compan... (3) Nondividend distributions (5) Section 199A dividends (6) Investment expenses U.S. bonds (nontaxable to state) (% or amount) Tax-exempt Interest Total municipal bonds In-state municipal bonds (percentage or amount) Certain private activity bonds (6251)(% or amount) Details: Dividend Income (1099-DIV) LA Investment Compan... Other State capital gain distributions (if different, -1=none){CA} State only taxable dividend {} Nominee total ordinary dividends Nominee qualified dividends Nominee capital gain distributions Nontaxable to federal {CA} 1=delete this year, 2=delete next year OMB No. 1545-0110 2020 Dividends and Distributions 9191 VOID CORRECTED PAYER'S name, street address, city or town, state or province, country, ZIP 1a Total ordinary dividends or foreign postal code, and telephone no. $ 3674.36 LA Investment Company 1b Qualified dividends 5 Lake Avenue 145.96 Pasadena, CA 91106 $ 2a Total capital gain distr. $ 622.78 PAYER'S federal identification number RECIPIENT'S identification number 2c Section 1202 gain 90-0077001 500-00-1000 Form 1099-DIV 2b Unrecap. Sec. 1250 gain $ 2d Collectibles (28%) gain Copy A For Internal Revenue Service Center File with Form 1096. $ RECIPIENT'S name $ 3 Nondividend distributions $ Marc Pennyworth 4 Federal income tax withheld $ 5 Investment expenses $ 7 Foreign country or U.S. possession Street address (including apt. no.) 6 Foreign tax paid 100 Major Street Apt 408 City or town, state or province, country, and ZIP or foreign postal code Pasadena, CA 91106 For Privacy Act and Paperwork Reduction Act Notice, see the General Instructions for Certain Information Returns. 8 Cash liquidation distributions $ 10 Exempt-interest dividends 9 Noncash liquidation distributions $ 11 Specified private activity bond interest dividends $ $ Account number (see instructions) 2nd TIN not. 12 State 13 State identification no. 14 State tax withheld $ $ Form 1099-DIV Cat. No. 14415N www.lrs.gov/form1099div 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 Details: Dividend Income (1099-DIV) LA Investment Compan... PRIOR YEAR AMOUNT Taxpayer Spouse Joint Dividend Income (1a) Total ordinary dividends 3,674 (1b) Qualified dividends 146 (2a) Total capital gain distributions 623 (2b) Unrecaptured section 1250 gain (2c) Section 1202 gain (2d) Collectibles (28%) rate gain Details: Dividend Income (1099-DIV) LA Investment Compan... (3) Nondividend distributions (5) Section 199A dividends (6) Investment expenses U.S. bonds (nontaxable to state) (% or amount) Tax-exempt Interest Total municipal bonds In-state municipal bonds (percentage or amount) Certain private activity bonds (6251)(% or amount) Details: Dividend Income (1099-DIV) LA Investment Compan... Other State capital gain distributions (if different, -1=none){CA} State only taxable dividend {} Nominee total ordinary dividends Nominee qualified dividends Nominee capital gain distributions Nontaxable to federal {CA} 1=delete this year, 2=delete next year