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Fidelity Institutional (CUST-FI-001) Statement Date:
as agent for Fidelity Institutional Tax Information
Menlo Park, CA 94025 Account 2016
Customer Service: 800-555-0199
PAYER'S EIN: 61-4327891 RECIPIENT'S SSN: XXX-XX-4444 / XXX-XX-8888
RECIPIENT: Alex & Sam Chen Household ID: HH-CHEN-001
3215 Lakeview Circle, Wayzata, MN 55391 Account: ACCT-TX01 ...7412
DIVIDENDS AND DISTRIBUTIONS 2016 1099-DIV INTEREST INCOME 2016 1099-INT
1a- Total ordinary dividends 850.24 1- Interest income 298.56
1b- Qualified dividends 680.19 3- Interest on U.S. Savings Bonds 0.00
2a- Total capital gain distributions 0.00 4- Federal income tax withheld 0.00
5- Section 199A dividends 0.00 8- Tax-exempt interest 0.00
12- Exempt-interest dividends 274.88 11- Bond premium 0.00
14- State tax withheld 0.00
SUMMARY OF PROCEEDS, GAINS & LOSSES, AND WITHHOLDING
Term Proceeds Cost basis Market discount Wash sale loss disallowed Net gain or loss(-)
Long 44,915.00 41,400.00 0.00 0.00 3,515.00
Grand total 44,915.00 41,400.00 0.00 0.00 3,515.00
Withholding
Federal income tax withheld 0.00
*This is important tax information and is being furnished to the Internal Revenue Service.
If you are required to file a return, a negligence penalty or other sanction may be imposed on
you if this income is taxable and the IRS determines that it has not been reported.
Fidelity Institutional (Synthetic) — Chen Household HH-CHEN-001 | CONFIDENTIAL | Synthetic Demo Data Only — Not Investment or Tax Advice | Page 1

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FORM 1099-DIV — DIVIDENDS & DISTRIBUTIONS
PAYER: Fidelity Institutional (CUST-FI-001) RECIPIENT: Alex & Sam Chen
EIN: 61-4327891 SSN: XXX-XX-4444 / XXX-XX-8888
Account: ACCT-TX01 ...7412 Tax Year: 2016
Securities: UECIX, IDEIX, MUNIX
Box Detail
Box 1a — Total Ordinary Dividends $850.24
Box 1b — Qualified Dividends (subset of 1a) $680.19
Box 2a — Total Capital Gain Distributions $0.00
Box 5 — Section 199A Dividends $0.00
Box 12 — Exempt-Interest Dividends (state/local tax-exempt) $274.88
Box 14 — State Tax Withheld $0.00
Qualified dividend eligibility based on required holding periods met for all equity index positions.
Exempt-interest dividends from MUNIX (MN Municipal Bond Fund) are exempt from federal and MN state income tax.
Fidelity Institutional (Synthetic) — Chen Household HH-CHEN-001 | CONFIDENTIAL | Synthetic Demo Data Only — Not Investment or Tax Advice | Page 2

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FORM 1099-B — PROCEEDS FROM BROKER TRANSACTIONS
Payer: Fidelity Institutional (CUST-FI-001) EIN: 61-4327891 Account: ACCT-TX01 ...7412
LONG-TERM Transactions — Basis Reported to IRS
Security Qty Date Sold Proceeds Cost Basis Gain / (Loss) Notes
IDEIX 1,200 2016-07-15 $14,640.00 $13,200.00 $1,440.00 Rebalancing — shift to UCBIX
STBIX 500 2016-09-12 $5,025.00 $4,980.00 $45.00 Emergency fund liquid
UCBIX 2,500 2016-11-08 $25,250.00 $23,220.00 $2,030.00 Rebalancing — equity trim
LONG-TERM Subtotal $44,915.00 $41,400.00 $3,515.00
NET REALIZED GAIN / (LOSS): $3,515.00
All transactions in ACCT-TX01 (Joint Taxable Brokerage). Covered security — cost basis reported to IRS.
Noncovered transactions: none for this account in this tax year. Wash sale rules applied where applicable.
Synthetic demo data — consult your tax advisor.
Fidelity Institutional (Synthetic) — Chen Household HH-CHEN-001 | CONFIDENTIAL | Synthetic Demo Data Only — Not Investment or Tax Advice | Page 3
