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Get For Calendar Year 20 OMB No

Ue Service Department of the Treasury , 20 Name of corporation Employer identification number Certain Dividends From 10/50 Corporations Section 901(j) Income: Name of Sanctioned Country Income Re-sourced by Treaty: Name of Country General Limitation Income Income or (Loss) Before Adjustments (Report all amounts in U.S. dollars. See page 5 of instructions. ) 1. Foreign Country or U.S. Possession (Enter two-letter code from list beginning on page 11 of instructions. Use a separate l.

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