Federal Changes in Corporate Control and Capital Structure

Changes in Corporate Control and Capital Structure
Form 1099-CAP (Rev. September 2019)
7373

VOID

CORRECTED

CORPORATION’S name, street address, city or town, state or province,
country, ZIP or foreign postal code, and telephone no.

1 Date of sale or exchange

OMB No. 1545-1814
Form

2 Aggregate amount rec’d*

1099-CAP

(Rev. September 2019)
For calendar year

20

$
CORPORATION’S TIN

SHAREHOLDER’S TIN

3 No. of shares exchanged

4 Classes of stock exchanged

Copy A
For
Internal Revenue
Service Center

SHAREHOLDER’S name

Street address (including apt. no.)
5
City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)
Form 1099-CAP (Rev. 9-2019)

Changes in
Corporate
Control and
Capital Structure

* The shareholder cannot claim a loss based on the
amount in box 2.
Cat. No. 35115M

www.irs.gov/Form1099CAP

File with Form 1096.
For Paperwork
Reduction Act
Notice, see the
current General
Instructions for
Certain Information
Returns.

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

CORRECTED (if checked)
CORPORATION’S name, street address, city or town, state or province,
country, ZIP or foreign postal code, and telephone no.

1 Date of sale or exchange

OMB No. 1545-1814
Form

2 Aggregate amount rec’d*

1099-CAP

(Rev. September 2019)
For calendar year

20

$
CORPORATION’S TIN

SHAREHOLDER’S TIN

Changes in
Corporate
Control and
Capital Structure

3 No. of shares exchanged

4 Classes of stock exchanged

Copy B
For Shareholder

SHAREHOLDER’S name

Street address (including apt. no.)
5
City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)
Form 1099-CAP (Rev. 9-2019)

* You cannot claim a loss based on the amount in box 2.

(keep for your records)

www.irs.gov/Form1099CAP

This is important tax
information and is being
furnished to the IRS. If
you are required to file a
return, a negligence
penalty or other
sanction may be
imposed on you if
taxable income results
from this transaction
and the IRS determines
that it has not been
reported.

Department of the Treasury - Internal Revenue Service

Instructions for Shareholder
A corporation in which you own stock that has had a
change in control or a substantial change in capital
structure must send you this statement by January 31 of
the year following the calendar year of the change. You
have received this statement because the corporation
has reasonably determined that you may be required to
recognize gain from the receipt of cash, stock, or other
property that was exchanged for the corporation’s
stock. Report any gain from the exchange on Form
8949. However, you cannot claim a (loss) on Form 8949
as a result of this exchange. See chapter 4 of Pub. 550
for additional information.
Shareholder’s taxpayer identification number (TIN).
For your protection, this form may show only the last
four digits of your TIN (social security number (SSN),
individual taxpayer identification number (ITIN), adoption
taxpayer identification number (ATIN), or employer
identification number (EIN)). However, the issuer has
reported your complete TIN to the IRS.

Account number. May show an account or other
unique number the payer corporation assigned to
distinguish your account.
Box 1. Shows the date the stock was exchanged for
cash, stock, or other property.
Box 2. Shows the aggregate amount of any cash and
the fair market value of any stock or other property
received by you in the exchange for the stock you held.
Box 3. Shows the number of shares of the corporation’s
stock that you held which were exchanged in the
transaction.
Box 4. Shows the class or classes of stock that were
exchanged.
Future developments. For the latest information about
developments related to Form 1099-CAP and its
instructions, such as legislation enacted after they were
published, go to www.irs.gov/Form1099CAP.

VOID

CORRECTED

CORPORATION’S name, street address, city or town, state or province,
country, ZIP or foreign postal code, and telephone no.

1 Date of sale or exchange

OMB No. 1545-1814
Form

2 Aggregate amount rec’d*

1099-CAP

(Rev. September 2019)
For calendar year

20

$
CORPORATION’S TIN

3 No. of shares exchanged

SHAREHOLDER’S TIN

Changes in
Corporate
Control and
Capital Structure

4 Classes of stock exchanged

Copy C
For Corporation

SHAREHOLDER’S name

Street address (including apt. no.)
5
City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)
Form 1099-CAP (Rev. 9-2019)

* The shareholder cannot claim a loss based on the
amount in box 2.
www.irs.gov/Form1099CAP

For Paperwork
Reduction Act
Notice, see the
current General
Instructions for
Certain Information
Returns.

Department of the Treasury - Internal Revenue Service

Instructions for Corporation
To complete Form 1099-CAP, use:
• The current General Instructions for Certain
Information Returns, and
• The current Instructions for Form 1099-CAP.
To get or to order these instructions, go to
www.irs.gov/Form1099CAP.
Filing and furnishing. For filing and furnishing
instructions, including due dates, and to request filing or
furnishing extensions, see the current General
Instructions for Certain Information Returns.

To file electronically, you must have software that
generates a file according to the specifications in Pub.
1220.
Need help? If you have questions about reporting on
Form 1099-CAP, call the information reporting customer
service site toll free at 866-455-7438 or 304-263-8700
(not toll free). Persons with a hearing or speech
disability with access to TTY/TDD equipment can call
304-579-4827 (not toll free).