SCHEDULE B
(Form 1040A or 1040)
Department of the Treasury, Internal Revenue Service (99)
Interest and Ordinary Dividends
Attach to Form 1040A or 1040.
Name(s) shown on return
Your social security number
Part I Interest
(See instructions on back and the instructions for Form 1040A, or Form 1040, line 8a.)
Note. If you received a Form 1099-INT, Form 1099-OID, or substitute statement from a brokerage firm, list the firm's name as the payer and enter the total interest shown on that form.
1 List name of payer. If any interest is from a seller-financed mortgage and the buyer used the property as a personal residence, see instructions on back and list this interest first. Also, show that buyer's social security number and address.
Amount
2 Add the amounts on line 1
3 Excludable interest on series EE and I U.S. savings bonds issued after 1989. Attach Form 8815
4 Subtract line 3 from line 2. Enter the result here and on Form 1040A, or Form 1040, line 8a
Note. If line 4 is over $1,500, you must complete Part III.
Part II Ordinary Dividends
(See instructions on back and the instructions for Form 1040A, or Form 1040, line 9a.)
Note. If you received a Form 1099-DIV or substitute statement from a brokerage firm, list the firm's name as the payer and enter the ordinary dividends shown on that form.
5 List name of payer, Amount
6 Add the amounts on line 5. Enter the total here and on Form 1040A, or Form 1040, line 9a
Note. If line 6 is over $1,500, you must complete Part III.
Part III Foreign Accounts and Trusts
(See instructions on back.)
You must complete this part if you (a) had over $1,500 of taxable interest or ordinary dividends; (b) had a foreign account; or (c) received a distribution from, or were a grantor of, or a transferor to, a foreign trust.
7a At any time during 2012, did you have a financial interest in or signature authority over a financial account (such as a bank account, securities account, or brokerage account) located in a foreign country? See instructions
b If “Yes,” are you required to file Form TD F 90-22.1 to report that financial interest or signature authority? See Form TD F 90-22.1 and its instructions for filing requirements and exceptions to those requirements
If you are required to file Form TD F 90-22.1, enter the name of the foreign country where the financial account is located
8 During 2012, did you receive a distribution from, or were you the grantor of, or transferor to, a foreign trust? If “Yes,” you may have to file Form 3520. See instructions on back