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Account or Owner Name (optional)
Enter your data separately for each tax lot (i.e. purchase date):
1. Name of stock paying a deemed redemption
or enter your own data:
2. Date of original purchase (mm/dd/yyyy) (tax lot)
3. Date of redemption payment (mm/dd/yyyy)
4. Number of shares owned for this tax lot (no commas)
5. Cost basis before redemption payment (total, not per share) $ (no commas)
6. Amount of redemption payment per share $ (no commas)
7. Market value per share prior to redemption $ (no commas)
Tax information statement