SCHEDULE B (Form 1040A or 1040) (Rev. January 2017) Department of the Treasury Internal Revenue Service (99) Name(s) shown on return Information Interest and Ordinary Dividends Attach to Form 1040A or 1040. about Schedule B and its instructions is at www.irs.gov/scheduleb. OMB No. 1545-0074 Attachment Sequence No. 08 Your social security number 2016 Amount 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 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. Add the amounts on line 1 . . . . . . . . . . Excludable interest on series EE and I U.S. savings Attach Form 8815 . . . . . . . . . . . . . 4 Subtract line 3 from line 2. Enter the result here and 1040, line 8a . . . . . . . . . . . . . . Note: If line 4 is over $1,500, you must complete Part III. List name of payer 5 2 3 ........ bonds issued after 1989. ........ on Form 1040A, or Form . . . . . . . . 2 3 4 Amount 5 Add the amounts on line 5. Enter the total here and on Form 1040A, or Form 6 1040, line 9a . . . . . . . . . . . . . . . . . . . . . . Note: If line 6 is over $1,500, you must complete Part III. 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. 7a At any time during 2016, 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 . . . . . . . . . . . . . . . . . . . . . . . . 6 Yes No Part III Foreign Accounts and Trusts (See instructions on back.) 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 2016, 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 . . . . . . Cat. No. 17146N Schedule B (Form 1040A or 1040) 2016 American LegalNet, Inc. www.FormsWorkFlow.com For Paperwork Reduction Act Notice, see your tax return instructions. Schedule B (Form 1040A or 1040) 2016 Page 2 If you received interest as a nominee, you must give the actual owner a Form 1099-INT (unless the owner is your spouse) and file Forms 1096 and 1099-INT with the IRS. For more details, see the General Instructions for Certain Information Returns and the Instructions for Forms 1099-INT and 1099-OID. Financial account. A financial account includes, but isn't limited to, a securities, brokerage, savings, demand, checking, deposit, time deposit, or other account maintained with a financial institution (or other person performing the services of a financial institution). A financial account also includes a commodity futures or options account, an insurance policy with a cash value (such as a whole life insurance policy), an annuity policy with a cash value, and shares in a mutual fund or similar pooled fund (that is, a fund that is available to the general public with a regular net asset value determination and regular redemptions). Financial account located in a foreign country. A financial account is located in a foreign country if the account is physically located outside of the United States. For example, an account maintained with a branch of a United States bank that is physically located outside of the United States is a foreign financial account. An account maintained with a branch of a foreign bank that is physically located in the United States isn't a foreign financial account. Signature authority. Signature authority is the authority of an individual (alone or in conjunction with another individual) to control the disposition of assets held in a foreign financial account by direct communication (whether in writing or otherwise) to the bank or other financial institution that maintains the financial account. See the FinCEN Form 114 instructions for exceptions. Don't consider the exceptions relating to signature authority in answering Question 1 on line 7a. Other definitions. For definitions of "financial interest," "United States," and other relevant terms, see the instructions for FinCEN Form 114. Line 7a­Question 2. See FinCEN Form 114 and its instructions at www.fincen.gov/fbar to determine whether you must file the form. Check the "Yes" box if you are required to file the form; check the "No" box if you aren't required to file the form. If you checked the "Yes" box to Question 2 on line 7a, you must electronically file FinCEN Form 114 with Treasury's Financial Crimes Enforcement Network; go to www.fincen.gov/fbar for details. Do not attach FinCEN Form 114 to your tax return. FinCEN Form 114 for 2016 is now generally due April 18, 2017, but FinCEN is providing an automatic extension for all filers until October 16, 2017. See www.fincen.gov for details. If you are required to file FinCEN Form 114 but don't properly do so, you may have to pay a civil penalty up to $10,000. A person who willfully fails to CAUTION report an account or provide account identifying information may be subject to a civil penalty equal to the greater of $100,000 or 50% of the balance in the account at the time of the violation. Willful violations may also be subject to criminal penalties. Line 7b. If you are required to file FinCEN Form 114, enter the name of the foreign country or countries in the space provided on line 7b. Attach a separate statement if you need more space. Line 8