Interest Income
Name:
EMail Address:
Payer Name	Box 1	Box 2	Box 3	Box 4	Box 5	Box 6	Box 7	Box 7B
	Interest Income not in Box 3	Early Withdrawl Penalty	Interest on U.S. Savings Bonds	Federal Tax W/H	Investment Exp	Foreign Tax Paid	Foreign Country	Foreign Income
Dividend Income
Payer Name	Ordinary Dividends	Qualified Dividends	Total Capital Gains Distrib.	Qualified 5 Year Gain	Unrecapture Section 1250 Gain	Section 1202 Gain	28% Rate Gain	Nontaxable Distributions	Federal Income Tax Withheld	Foreign Tax Paid
Gain Loss from sale of Assets, Stock, securities, and other capital assets.
Kind of Property or Name of Stock	Date Acquired		Date Sold		Sales Price		Original Cost