Page 69 - 5D.Charlotte.Sydney

Form 1099-DIV
Form 1099-INT
*
1 Interest Income
*
6 Foreign Tax Paid
P.O. Box 28019
8 Tax-Exempt Interest
5 Investment Expenses
2 Early Withdrawal Penalty
2a Total Capital Gain Distributions
4 Federal Income Tax Withheld
SYDNEY KATE BLOCK
Albuquerque, NM 87125-8019
7 Foreign Country or U.S. Possession
9 Specified Private Activity Bond Interest
101 COMMONWEALTH AVE
FIDELITY BROKERAGE SERVICES LLC
Envelope
SAN FRANCISCO CA 94118-2603
3 Interest on U.S. Savings Bonds and Treas. Obligations
9001 572464 04
02/09/2020 9001572464

..........................................................................
2c Section 1202 Gain..................................................................................................0.00
3 Nondividend Distributions ......................................................................................0.00
2d Collectibles (28%) Gain..........................................................................................0.00
4 Federal Income Tax Withheld .............................................................................0.00
6 Investment Expenses.............................................................................................0.00
5 Section 199A Dividends.........................................................................................0.69
1b Qualified Dividends ............................................................................................233.66
1a Total Ordinary Dividends ...................................................................................393.17
2b Unrecap. Sec 1250 Gain........................................................................................0.00
.............................................................................2.68
.....................................0.00
..........................................................................................0.00
.................................................................................................0.00
..........................................................................0.00
....................................................................................0.00
...................................................................................................1.75
............................................................................................0.00
..............................................................0.00
on you if this income is taxable and the IRS determines that it has not been reported.
SYDNEY KATE BLOCK
15 State
2019 Dividends and Distributions
2019 Interest Income
11 Bond Premium
10 Market Discount
17 State Tax Withheld

16 State Identification No

14 Tax-Exempt Bond CUSIP no.
Account No.
13 Bond Premium on Tax-Exempt Bond
Recipient ID No.
12 Bond Premium on U.S. Treasury Obligations
JERSEY CITY, NJ 07310
645-171491
***-**-9184
499 WASHINGTON BLVD
Payer's Name and Address:
Pages 1 of 10
NATIONAL FINANCIAL SERVICES LLC
Customer Service:
Payer's Fed ID Number:
....................................................................................
...........................................................................................................................
..............................................................................................0.00
.....................................................0.00
..................................................................0.00
14 State Identification No...................................................................................................
13 State..............................................................................................................................
8 Foreign Country or U.S. Possession.................................................................Various
................................................................................................
....................................................................................................0.00
..................................................................................................0.00
11 Exempt Interest Dividends .....................................................................................0.00
10 Non-Cash Liquidation Distributions........................................................................0.00
15 State Tax Withheld.................................................................................................0.00
12 Specified Private Activity Bond Interest Dividends.................................................0.00
7 Foreign Tax Paid....................................................................................................8.45
9 Cash Liquidation Distributions................................................................................0.00
Copy B for Recipient
Copy B for Recipient
(OMB No. 1545-0112)
2019 TAX REPORTING STATEMENT
(OMB No. 1545-0110)
* 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
04-3523567
415-326-7650