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Enter your data separately for each tax lot (i.e. purchase date):
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Name of original stock
1. Name of new stock received
2. Date of purchase (tax lot) (mm/dd/yyyy)
3. Number of shares of original stock, adjusted for splits since purchase (no commas)
4. Total cost of original stock purchase, including commissions & fees, adjusted for previous spinoffs and return of capital (for all shares, not per share) $ (no commas)
5. Date of exchange (mm/dd/yyyy)
6. Exchange ratio of new stock per share of original stock (for example, 0.6725)
7. Number of whole shares of new stock you received (no commas)
8. Number of fractional shares of new stock you received (.xxx)
9. Cash to boot received for old stock (per share) $ (no commas)
10. Total cash to boot you received for old stock (not per share) $ (no commas)
11. Cash in lieu received for fractional shares (enter 0.00 if none) $
12. Fair market value per share of new stock received (opening, average or closing price at time of merger) $
13. Enter 1 if normal cash to boot rules, 2 if fully taxable proceeds, 3 if redemption, 4 if taxable dividend, 5 if PFIC with QEF election, 6 if PFIC with mark to market election, 7 if PFIC with no election, 8 if PFIC with deemed sale election
13. Additional comments if any
14. Name of tax information statement if available
14. Name of account or owner (optional)