Form 1040 (Schedule B) - Interest and Ordinary Dividends Form (2015)

SCHEDULE B
(Form 1040A or 1040)
Department of the Treasury
Internal Revenue Service (99)
Interest and Ordinary Dividends
Attach to Form 1040A or 1040.
Information about Schedule B and its instructions is at www.irs.gov/scheduleb.
OMB No. 1545-0074
2015
Attachment
Sequence No.
08
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
1
Amount
2 Add the amounts on line 1 . . . . . . . . . . . . . . . . . . 2
3
Excludable interest on series EE and I U.S. savings bonds issued after 1989.
Attach Form 8815 . . . . . . . . . . . . . . . . . . . . .
3
4
Subtract line 3 from line 2. Enter the result here and on Form 1040A, or Form
1040, line 8a . . . . . . . . . . . . . . . . . . . . . .
4
Note: If line 4 is over $1,500, you must complete Part III.
Amount
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
5
6
Add the amounts on line 5. Enter the total here and on Form 1040A, or Form
1040, line 9a . . . . . . . . . . . . . . . . . . . . . .
6
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.
Yes No
7a At any time during 2015, 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 . . . . . . . . . . . . . . . . . . . . . . . .
If “Yes,” are you required to file FinCEN Form 114, Report of Foreign Bank and Financial
Accounts (FBAR), to report that financial interest or signature authority? See FinCEN Form 114
and its instructions for filing requirements and exceptions to those requirements . . . . . .
b
If you are required to file FinCEN Form 114, enter the name of the foreign country where the
financial account is located
8 During 2015, 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 . . . . . .
For Paperwork Reduction Act Notice, see your tax return instructions.
Cat. No. 17146N Schedule B (Form 1040A or 1040) 2015
Page 1/2
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Form 1040 (Schedule B) - Interest and Ordinary Dividends Form (2015) PDF

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