SCHEDULE K-1 (Form 1041) Beneficiary's Share of Income, Deductions, Credits, etcetera 2012

• Part I: Information About the Estate or Trust

• A. Estate's or trust's employer identification number field contains 10–0123456
• B. Estate's or trust's name field contains Estate of John R. Smith
• C. Fiduciary's name, address, city, state and ZIP code field contains Charles R. Smith, Executor, 6406 Mayflower Street, Juneville, ME 00000

• • Part II: Information About the Beneficiary

  • F. Beneficiary's identifying number field contains 123-00-6789
  • G. Beneficiary's name, address, city, state, and ZIP code field contains James Smith, 6407 Mayflower Street, Juneville, ME 00000
  • H. Checkbox Domestic beneficiary checkbox checked

• • Part III: Beneficiary's Share of Current Year Income, Deductions, Credits, and Other Items

  • 1. Interest income field contains 300
  • 2a. Ordinary dividends field contains 100
  • 2b. Qualified dividends field contains 100
  • 5. Other portfolio and nonbusiness income field contains 1,600

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