,T#C ----            ,T#C ,,SCH #H 7#JB7

               ,S*$ULE #H
     ,9VE/;T ,9COME1 ,C>RY+ ,*>GES1
     & ,GROSS-,UP ,AM.T ( ,DIVID5DS
            ,RETA9$ 0! ,TRU/
    
  --,5T] ! APPLICA# TAX,N YE> 9 ! BOX
    ABV4
  
       ,"P ;,A--,CALCULAT+ 9VE/;T
          9COME & C>RY+ *>GES
    
  --,ATTA* ANY 9=M,N SLIPS RCVD4
  --,5T] ! "NS (! PAY]S AT ! APPROPRIATE
    L9ES 2L4 ,IF "! IS N 5 SPACE1 ATTA*
    A SEP>ATE %EET4
  --,9CLUDE AM.TS CR$IT$ "? BANKS1 TRU/
    -PANIES1 BROK]S1 ETC4
  




                                      #A
               ,S*$ULE #H
7#A7 ..,ACTUAL AM.T ( DIVID5DS F
  TAXA# ,CANADIAN .CORPOR,NS 7BOX
  #BC ( ,T#C SLIP1 OR BOX #AJ (
  ,T#E SLIP7 """""""""""""""""""" 4#----
,5T] ! AM.T F L9E #A 6L9E #JC (!
  RETURN1 & L9E #AF 2L4

          ,=EIGN 9VE/;T 9COME
    
7#B7 ,9T]E/ F =EIGN S\RCES """""" 4#----
7#C7 ,O!R =EIGN 9VE/;T 9COME """" 4#----
7#D7 ..,TOTAL =EIGN 9VE/;T .9COME
  7L9E #B PLUS L9E #C7 """""""""" 4#----
,5T] ! AM.T F L9E #D 6L9E #JD (!
  RETURN4

           ,O!R 9VE/;T 9COME
    
,9T]E/ F3
7#E7 ,BONDS1 TRU/ -PANIES1 BANKS  4#----
7#F7 ,O!R DEPOSITS 7SPECIFY7 ---- 4#----
7#G7 ,MORTGAGES1 NOTES1 & O!R
  SECURITIES """""""""""""""""""" 4#----
                                      #B
               ,S*$ULE #H
7#H7 ,O!R DIVID5DS 79CLUD+
  DIVID5DS RCVD "U A DIVID5D
  R5TAL >RANGE;T7 """"""""""""""" 4#----
7#I7 ,O!R 7SPECIFY7 ---- """""""" 4#----
7#AJ7 ..,TOTAL O!R 9VE/;T .9COME
  7ADD L9ES #E 6#I7 """"""""""""" 4#----
,5T] ! AM.T F L9E #AJ 6L9E #JE ON
  ! RETURN4

      ,C>RY+ *>GES & 9T]E/ EXP5SES
    
7#AA7 ,9T]E/ ON M"OY BORR[$ 6E>N
  9VE/;T 9COME 7ATTA* A /ATE;T--
  SEE ! GUIDE = DETAILS7 """""""" 4#----
7#AB7 ,MANAGE;T1 SAFE CU/ODY1 OR
  A3.T+ FEES 7SPECIFY7 ---- """"" 4#----
7#AC7 ,9VE/;T C\NSEL FEES """"""" 4#----
7#AD7 ,O!R 7SPECIFY7 ---- """"""" 4#----
7#AE7 .,TOTAL .C>RY+ .*>GES 7ADD
  L9ES #AA 6#AD7 """""""""""""""" 4#----
,5T] ! AM.T F L9E #AE ON L9E #BA
  (! RETURN4

                                      #C
     ,"P ;,B--,CALCULAT+ ! GROSS-UP
      AM.T ( DIVID5DS RETA9$ OR N
           DESIGNAT$ 0! TRU/
    
7#AF7 ,TOTAL DIVID5DS
  REPORT$ 2F APPLY+
  EXP5SES 7L9E #A ABV7 """ 4#----
7#AG7 ,DIVID5DS DESIGNAT$
  6B5EFICI>IES 7L9E #IBC1
  ,"P ;,A ( ,S*$ULE #I7 "" 4#----
7#AH7 ,TOTAL DIVID5DS
  RETA9$ OR .N DESIGNAT$
  0! TRU/ 7L9E #AF M9US
  L9E #AG7 """"""""""""""" 4#----
7#AI7 & 7#HBDJ7 ,DIVID5DS
  ALLOCAT$1 B .N
  DESIGNAT$1 6NON-RESID5T
  B5EFICI>IES 7DIVID5DS F
  L9E #IBF1 ,COLUMN #B (
  ,S*$ULE #I7 """""""""""" 4#----
7#BJ7 ,TOTAL DIVID5DS
  RETA9$ 7RESID5T
  B5EFICI>IES ONLY7 OR .N
  DESIGNAT$ 0! TRU/ 7L9E
  #AH M9US L9E #AI7 """""" 4#----     #D
               ,S*$ULE #H
7#BA7 ..,GROSS-UP AM.T (
  DIVID5DS RETA9$ OR N
  DESIGNAT$ 0! .TRU/
  MULTIPLI$ 0#BE@3P """"""""""""" 4#----

  ,5T] ! AM.T F L9E #BA ON L9E #BD (
,S*$ULE #AA1 ,F$]AL ,9COME ,TAX1 OR ON
L9E #AI ( ,S*$ULE #AB1 ,M9IMUM ,TAX1 IF
APPLICA#1 & ON L9E #DI (! RETURN4














                                      #E