IV: DIVIDENDS AND DISTRIBUTIONS (OMB NO. 1545-0110) la Total Ordinary Dividends 1b Qualified Dividends 2a Total Capital Gains Distribution 2b Unrecap Sec. 1250 gain 2c Section 1202 gain 2d Collectibles (28%) gain 3 Non dividend distributions 4 Federal income tax withheld 5 Investment Expenses

est Income not included in box 3 5763.74 1b Qualified Dividends $4,130.88 2 Early vAthdrawal penalty 2a 2b Total Capital Gain Distributions Unrecap Sec. 1250 gain 3 Interest on U.S. Savings Bonds & Treasury obligations 2c Section 1202 gain 4 Federal income tax withheld 2d Collectibles (28%)g

est Income not included in box 3 5763.74 1b Qualified Dividends $4,130.88 2 Early vAthdrawal penalty 2a 2b Total Capital Gain Distributions Unrecap Sec. 1250 gain 3 Interest on U.S. Savings Bonds & Treasury obligations 2c Section 1202 gain 4 Federal income tax withheld 2d Collectibles (28%)g