Fill and Sign the Medical Report for University Form

Attention: This form is provided for informational purposes only. Copy A appears in red, similar to the official IRS form. Do not file copy A downloaded from this website. The official printed version of this IRS form is scannable, but the online version of it, printed from this website, is not. A penalty of $50 per information return may be imposed for filing forms that cannot be scanned. To order official IRS forms, call 1-800-TAX-FORM (1-800-829-3676) or Order Information Returns and Employer Returns Online, and we’ll mail you the scannable forms and other products. See IRS Publications 1141, 1167, 1179 and other IRS resources for information about printing these tax forms. 7979 VOID CORRECTED PAYER’S name, street address, city, state, ZIP code, and telephone no. 1a Date of sale or exchange OMB No. 1545-0715 2011 1b Date of acquisition Form 2 Stocks, bonds, etc. $ PAYER’S federal identification number RECIPIENT’S identification number 3 Cost or other basis Reported to IRS ͖ 1099-B Gross proceeds Gross proceeds less commissions and option premiums 4 Federal income tax withheld $ $ 5 Wash sale loss disallowed RECIPIENT’S name Proceeds From Broker and Barter Exchange Transactions 6 Check if a noncovered security $ 7 Street address (including apt. no.) 8 Type of gain or loss Short-term Long-term 9 City, state, and ZIP code Account number (see instructions) Description 2nd TIN not. 10 Profit or (loss) realized in 2011 on closed contracts $ $ $ Form 1099-B File with Form 1096. For Privacy Act and Paperwork Reduction Act Notice, see the 2011 General Instructions for Certain Information Returns. $ 15 Check if loss not allowed based on amount in box 2 $ Cat. No. 14411V Do Not Cut or Separate Forms on This Page For Internal Revenue Service Center 11 Unrealized profit or (loss) on 14 Bartering open contracts—12/31/2010 12 Unrealized profit or (loss) on 13 Aggregate profit or (loss) on contracts open contracts—12/31/2011 CUSIP number Copy A — Department of the Treasury - Internal Revenue Service Do Not Cut or Separate Forms on This Page CORRECTED (if checked) PAYER’S name, street address, city, state, ZIP code, and telephone no. 1a Date of sale or exchange OMB No. 1545-0715 2011 1b Date of acquisition Form 2 Sales price of stocks, bonds, etc. $ PAYER’S federal identification number RECIPIENT’S identification number 3 Cost or other basis Reported to IRS ͖ Proceeds From Broker and Barter Exchange Transactions 1099-B Sales price Sales price less commissions and option premiums 4 Federal income tax withheld Copy B For Recipient $ RECIPIENT’S name $ 5 Wash sale loss disallowed 6 If this box is checked, boxes 1b, 3, 5, and 8 may be blank $ Street address (including apt. no.) 7 8 Type of gain or loss Short-term Long-term City, state, and ZIP code 9 Description Account number (see instructions) 10 Profit or (loss) realized in 2011 on closed contracts CUSIP number 12 Unrealized profit or (loss) on 13 Aggregate profit or (loss) on contracts open contracts—12/31/2011 $ $ Form 1099-B (keep for your records) This is important tax information and is being furnished to the Internal Revenue Service. If you are required to file a return, a negligence penalty or other sanction may be imposed on you if this income is taxable and the IRS determines that it has not been reported. 11 Unrealized profit or (loss) on 14 Bartering open contracts—12/31/2010 $ $ 15 If box checked, loss based on amount in box 2 is not allowed $ Department of the Treasury - Internal Revenue Service Instructions for Recipient Brokers and barter exchanges must report proceeds from transactions to you and the IRS on Form 1099-B. Reporting is also required when your broker knows or has reason to know that a corporation in which you own stock has had a reportable change in control or capital structure. You may be required to recognize gain from the receipt of cash, stock, or other property that was exchanged for the corporation’s stock. If your broker reported this type of transaction to you, the corporation is identified in box 9. Account number. May show an account or other unique number the payer assigned to distinguish your account. CUSIP number. For broker transactions, may show the CUSIP (Committee on Uniform Security Identification Procedures) number of the item reported. Box 1a. Shows the trade date of the sale or exchange. For short sales, the date shown is the date the security was delivered to close the short sale. For aggregate reporting in boxes 10 through 13, no entry will be present. Box 1b. This box may be blank if box 6 is checked or if the securities sold were acquired on a variety of dates. For short sales, the date shown is the date you acquired the security delivered to close the short sale. Box 2. Shows the aggregate cash proceeds from transactions involving stocks, bonds, other debt obligations, commodities, or forward contracts. May show the proceeds from the disposition of your interest(s) in a widely held fixed investment trust. May also show the aggregate amount of cash and the fair market value of any stock or other property received in a reportable change in control or capital structure arising from the corporate transfer of property to a foreign corporation. Losses on forward contracts are shown in parentheses. This box does not include proceeds from regulated futures contracts. The broker must indicate whether the sales price or the sales price less commissions (including transfer taxes) and option premiums was reported to the IRS. Report this amount as explained in the instructions for Schedule D (Form 1040). Box 3. Shows the cost or other basis of securities sold. If box 6 is checked, box 3 may be blank. See the Schedule D (Form 1040) instructions or Pub. 550 for details about basis. Box 4. Shows backup withholding. Generally, a payer must backup withhold if you did not furnish your taxpayer identification number to the payer. See Form W-9 for information on backup withholding. Include this amount on your income tax return as tax withheld. Box 5. Shows the amount of nondeductible loss in a wash sale transaction. For details on wash sales, see the Schedule D (Form 1040) instructions and Pub. 550. Box 6. If this box is checked, the securities sold were noncovered securities and boxes 1b, 3, 5, and 8 may be blank. Generally, a noncovered security is a security other than stock; stock purchased before 2011; stock in most mutual funds and other regulated investment companies; and stock held in a dividend reinvestment plan in 2011. Box 8. Shows type of gain or loss. Box 9. Shows a brief description of the item or service for which the proceeds or bartering income is being reported. For regulated futures contracts and forward contracts, “RFC” or other appropriate description may be shown. For a corporation that had a reportable change in control or capital structure, this box may show the class of stock as C (common), P (preferred), or O (other). Regulated Futures Contracts (Boxes 10 Through 13): Box 10. Shows the profit or (loss) realized on regulated futures or foreign currency contracts closed during 2011. Box 11. Shows any year-end adjustment to the profit or (loss) shown in box 10 due to open contracts on December 31, 2010. Box 12. Shows the unrealized profit or (loss) on open contracts held in your account on December 31, 2011. These are considered sold as of that date. This will become an adjustment reported in box 11 in 2012. Box 13. Boxes 10, 11, and 12 are all used to figure the aggregate profit or (loss) on regulated futures or foreign currency contracts for the year. Include this amount on your 2011 Form 6781. Box 14. Shows the cash you received, the fair market value of any property or services you received, and the fair market value of any trade credits or scrip credited to your account by a barter exchange. See Pub. 525. Box 15. If checked, you cannot take a loss on your tax return based on gross proceeds from a reportable change in control or capital structure reported in box 2. Do not report this loss on Schedule D (Form 1040). The broker should advise you of any losses on a separate statement. VOID CORRECTED PAYER’S name, street address, city, state, ZIP code, and telephone no. 1a Date of sale or exchange OMB No. 1545-0715 2011 1b Date of acquisition Form 2 Stocks, bonds, etc. $ PAYER’S federal identification number ͖ 1099-B Gross proceeds Gross proceeds less commissions and option premiums 3 Cost or other basis 4 Federal income tax withheld $ RECIPIENT’S name RECIPIENT’S identification number Reported to IRS Proceeds From Broker and Barter Exchange Transactions $ 5 Wash sale loss disallowed 6 Check if a noncovered security $ Street address (including apt. no.) 7 8 Type of gain or loss Short-term Long-term City, state, and ZIP code Account number (see instructions) 9 Description 2nd TIN not. 10 Profit or (loss) realized in 2011 on closed contracts $ CUSIP number 1099-B For Privacy Act and Paperwork Reduction Act Notice, see the 2011 General Instructions for Certain Information Returns. 11 Unrealized profit or (loss) on 14 Bartering open contracts—12/31/2010 $ 12 Unrealized profit or (loss) on 13 Aggregate profit or (loss) on contracts open contracts—12/31/2011 $ Form Copy C For Payer $ 15 Check if loss not allowed based on amount in box 2 $ Department of the Treasury - Internal Revenue Service Instructions for Payer General and specific form instructions are provided as separate products. The products you should use to complete Form 1099-B are the 2011 General Instructions for Certain Information Returns and the 2011 Instructions for Form 1099-B. A chart in the general instructions gives a quick guide to which form must be filed to report a particular payment. To order these instructions and additional forms, visit IRS.gov or call 1-800-TAX-FORM (1-800-829-3676). Caution: Because paper forms are scanned during processing, you cannot file with the IRS Forms 1096, 1097, 1098, 1099, 3921, 3922, or 5498 that you print from the IRS website. Due dates. Furnish Copy B of this form to the recipient by February 15, 2012. File Copy A of this form with the IRS by February 28, 2012. If you file electronically, the due date is April 2, 2012. To file electronically, you must have software that generates a file according to the specifications in Pub. 1220, Specifications for Filing Forms 1097, 1098, 1099, 3921, 3922, 5498, 8935, and W-2G Electronically. The IRS does not provide a fill-in form option. Foreign recipient. If the recipient of the proceeds is a nonresident alien, you may have to withhold federal income tax and file Form 1042-S, Foreign Person’s U.S. Source Income Subject to Withholding. See the Instructions for Form 1042-S and Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign Entities. Need help? If you have questions about reporting on Form 1099-B, call the information reporting customer service site toll free at 1-866-455-7438 or 304-263-8700 (not toll free). For TTY/TDD equipment, call 304-579-4827 (not toll free). The hours of operation are Monday through Friday from 8:30 a.m. to 4:30 p.m., Eastern time.