Name: _____________________________________________________

Social Security Number: _______________________________________

Notes/Instructions:

1. Include broker commissions in the cost and total sales proceeds of the asset.
    
2. Separate sales into the short and long term categories. If you sell 500 shares of IBM and 200 of the shares were purchased one month ago, and 300 shares were purchased 12 or more months ago, record the Short Term gain / (loss) of the 200 shares on the first chart and record the 300 Long Term gain / (loss) on the second chart.
    
3. Only include capital gain / loss portion of mutual funds here. Mutual fund dividends should be reported as "dividends'.
    
4. Do you have capital losses to be carried forward from a prior year? ____________
    
5. Do not include retirement transactions (IRA, 401-k, etc.) on this form.
    
6. Please provide us with the appropriate 1099's.

Name: _______________________________________________________

Social Security Number: _______________________________________