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Enter your data separately for each tax lot (i.e. purchase date):
1. Name of original stock
or enter your own data:
2. Name of new stock received
3. Date of change in domicile (mm/dd/yyyy)
4. Purchase date for original stock (mm/dd/yyyy)
5. Exchange ratio (number of new shares for each original share)
6. Tax status of change in domicile--enter 1 if Sec 367 recognize gain but not loss, 2 if non-taxable, 3 if fully taxable
7. Number of shares of original stock prior to change in domicile (no commas)
8. Total cost basis for original stock, including commissions and fees, adjusted for previous spinoffs (total, not per share) $ (no commas)
9. Cash received in lieu of fractional shares (often denoted as CIL) (enter 0.00 if none) $
10. If the tax status is taxable, provide the market value per share of the new stock on the date of the move (open, average, or closing price.) Use the market value per share that the brokerage firm used to compute the taxable proceeds on your Form 1099. $(no commas)
11. Account or Owner Name (optional)
12. Comment
13. Name of tax information statement, if available