Schedule 1 Department of the Treasury—Internal Revenue Service

(Form 1040A) Interest and Dividend Income

for Form 1040A Filers 1991 OMB No. 1545-0085
Name(s) shown on Form 1040A Your social security number

Part I Complete this part and attach Schedule 1 to Form 1040A if:
● You have over $400 in taxable interest, or
Interest
● You are claiming the exclusion of interest from series EE U.S. savings bonds issued after 1989.
income
If you are claiming the exclusion or you received, as a nominee, interest that actually
(See pages 26 belongs to another person, see page 50.
and 50.) Note: If you received a Form 1099–INT, Form 1099–OID, or substitute statement, from a
brokerage firm, enter the firm’s name and the total interest shown on that form.
1 List name of payer Amount
1

2 Add the amounts on line 1. 2

3 Enter the excludable savings bond interest, if any, from Form
8815, line 14. Attach Form 8815 to Form 1040A. 3
4 Subtract line 3 from line 2. Enter the result here and on Form
1040A, line 8a. 4
Part II Complete this part and attach Schedule 1 to Form 1040A if you received over $400 in dividends.
If you received, as a nominee, dividends that actually belong to another person, see page 51.
Dividend
Note: If you received a Form 1099–DIV, or substitute statement, from a brokerage firm, enter
income
the firm’s name and the total dividends shown on that form.
(See pages 26
5 List name of payer Amount
and 51.)
5

6 Add the amounts on line 5. Enter the total here and on Form
1040A, line 9. 6
For Paperwork Reduction Act Notice, see Form 1040A instructions. Cat. No. 12075R Schedule 1 (Form 1040A) 1991