FIDELITY BROKERAGE SERVICES LLC 2021 TAX REPORTING STATEMENT
P.O. Box 28019 DENISE ANN VALENTI Account No. Z09-224840 Customer Service: 800-544-6666
Albuquerque, NM 87125-8019 Recipient ID No. ***-**-9492 Payer's Fed ID Number: 04-3523567
eDelivered
Payer's Name and Address:
NATIONAL FINANCIAL SERVICES LLC
DENISE ANN VALENTI 499 WASHINGTON BLVD
274 LARKSPUR LN JERSEY CITY, NJ 07310
HATFIELD PA 19440-3084
Form 1099-DIV * 2021 Dividends and Distributions Copy B for Recipient
(OMB No. 1545-0110)
1a Total Ordinary Dividends .......................................................................................0.00 7 Foreign Tax Paid....................................................................................................0.00
1b Qualified Dividends ................................................................................................0.00 8 Foreign Country or U.S. Possession.............................................................................
2a Total Capital Gain Distributions .............................................................................0.00 9 Cash Liquidation Distributions................................................................................0.00
2b Unrecap. Sec 1250 Gain........................................................................................0.00 10 Non-Cash Liquidation Distributions........................................................................0.00
2c Section 1202 Gain..................................................................................................0.00 11 Exempt Interest Dividends .....................................................................................0.00
2d Collectibles (28%) Gain..........................................................................................0.00 12 Specified Private Activity Bond Interest Dividends.................................................0.00
3 Nondividend Distributions ......................................................................................0.00 13 State..............................................................................................................................
4 Federal Income Tax Withheld .............................................................................0.00 14 State Identification No. ..................................................................................................
5 Section 199A Dividends .........................................................................................0.00 15 State Tax Withheld.................................................................................................0.00
6 Investment Expenses.............................................................................................0.00
Form 1099-INT * 2021 Interest Income Copy B for Recipient
(OMB No. 1545-0112)
1 Interest Income ................................................................................................... 0.00 10 Market Discount .................................................................................................. 0.00
2 Early Withdrawal Penalty .................................................................................... 0.00 11 Bond Premium .................................................................................................... 0.00
3 Interest on U.S. Savings Bonds and Treas. Obligations ..................................... 0.00 12 Bond Premium on U.S. Treasury Obligations ..................................................... 0.00
4 Federal Income Tax Withheld .......................................................................... 0.00 13 Bond Premium on Tax-Exempt Bond .................................................................. 0.00
5 Investment Expenses .......................................................................................... 0.00 14 Tax-Exempt Bond CUSIP no. ........................................................................... .........
6 Foreign Tax Paid ................................................................................................. 0.00 15 State .......................................................................................................................... .
7 Foreign Country or U.S. Possession .................................................................... ...... 16 State Identification No ............................................................................................... .
8 Tax-Exempt Interest ............................................................................................ 0.00 17 State Tax Withheld .............................................................................................. 0.00
9 Specified Private Activity Bond Interest .............................................................. 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.
01/17/2022 9001000000 Pages 1 of 6
2021 TAX REPORTING STATEMENT
DENISE ANN VALENTI Account No. Z09-224840 Customer Service: 800-544-6666
Recipient ID No. ***-**-9492 Payer's Fed ID Number: 04-3523567
Form 1099-MISC * 2021 Miscellaneous Information Copy B for Recipient
(OMB No. 1545-0115)
2 Royalties .............................................................................................................. 0.00
3 Other Income ....................................................................................................... 0.00 15 State Tax Withheld ............................................................................................... 0.00
4 Federal Income Tax Withheld ........................................................................... 0.00 16 State/Payer’s State No. .............................................................................................. .
8 Substitute Payments in Lieu of Dividends or Interest .......................................... 0.00 17 State Income ........................................................................................................ 0.00
Summary of 2021 Proceeds From Broker and Barter Exchange Transactions
1099-B Section Total Total Total Total Realized Federal
Proceeds Cost Basis Market Wash Gain/Loss Income Tax
Discount Sales Withheld
Short-term transactions for which basis is reported to the IRS 2,627.24 822.50 0.00 0.00 1,804.74 0.00
Short-term transactions for which basis is not reported to the IRS 0.00 0.00 0.00 0.00 0.00 0.00
Long-term transactions for which basis is reported to the IRS 0.00 0.00 0.00 0.00 0.00 0.00
Long-term transactions for which basis is not reported to the IRS 0.00 0.00 0.00 0.00 0.00 0.00
Transactions for which basis is not reported to the IRS and Term is Unknown 0.00 0.00 0.00 0.00 0.00 0.00
2,627.24 822.50 0.00 0.00 1,804.74 0.00
1099-B amounts are reported individually to the IRS. Refer to the Form 1099-B sections in this statement, if applicable.
Summary of 2021 Original Issue Discount
Total Original Issue Discount .....................................................................................0.00 Total Original Issue Discount - REMIC ...................................................................... 0.00
Total Original Issue Discount on U.S. Treasury Obligations .....................................0.00
Total Original Issue Discount on Tax-Exempt Obligations ........................................0.00 Original Issue Discount (OID) amounts are reported individually to the IRS. Refer to the Form
1099-OID pages in this statement, if applicable.
* 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.
01/17/2022 9001000000 Pages 2 of 6
2021 TAX REPORTING STATEMENT
DENISE ANN VALENTI Account No. Z09-224840 Customer Service: 800-544-6666
Recipient ID No. ***-**-9492 Payer's Fed ID Number: 04-3523567
0 00
FORM 1099-B* Copy B for Recipient OMB No. 1545-0715
2021 Proceeds from Broker and Barter Exchange Transactions
Short-term transactions for which basis is reported to the IRS --report on Form 8949 with Box A checked and/or Schedule D, Part I
Proceeds are reported as gross proceeds unless otherwise indicated (a).(This Label is a Substitute for Boxes 2, 5, 6 & 12)
(IRS Form 1099-B box numbers are shown below in bold type)
1a Description of property, Stock or Other Symbol, CUSIP
Action Quantity 1b Date 1c Date Sold 1d Proceeds 1e Cost or 1f Accrued 1g Wash Sale Gain/Loss (-) 4 Federal 14 State
Acquired or Disposed Other Basis (b) Market Loss Income Tax 16 State Tax
Discount Disallowed Withheld Withheld
ACCOLADE INC COM, ACCD, 00437E102
Sale 47.000 02/09/21 02/09/21 2,627.24 822.50(e) 1,804.74
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
TOTALS 2,627.24 822.50 0.00 0.00 0.00
Box A Short-Term Realized Gain 1,804.74
Box A Short-Term Realized Loss 0.00
For any transaction listed on Form 1099-B in a section indicating that "basis is reported to the IRS", we are reporting to the IRS: 1a Description of Property, 2 type of gain or loss (i.e. short-term or
long-term), 3 Proceeds from QOF (Qualified Opportunity Fund), 6 Gross or Net Proceeds, 12 basis reported to IRS, and columns 1b, 1c, 1d, 1e, 1f, 1g, 4, 7, 14, 15 and 16. We are not reporting to the
IRS: the Action, the Gain/Loss, and all subtotals and totals.
For any transaction listed on Form 1099-B in a section indicating that "basis is not reported to the IRS", we are reporting to the IRS: 1a Description of Property, 3 Proceeds from QOF (Qualified
Opportunity Fund), 5 Noncovered security, 6 Gross or Net Proceeds, and columns 1c, 1d, 4, 14, 15 and 16. We are not reporting to the IRS: 2 type of gain or loss (i.e. short-term or long-term), the Action,
the Gain/Loss, columns 1b, 1e, 1f, 1g, 2, 7 and 12 and all subtotals and totals.
For any section 1256 option contracts we are reporting to the IRS: 1a Description of Property and totals for boxes 8, 9, 10 and 11.
Although Fidelity makes every effort to provide accurate information, please bear in mind that you, the taxpayer, are ultimately responsible for the accuracy of your tax returns.
(b) Cost or other basis provided may include adjustments including, but not limited to, dividend reinvestment, return of capital/principal, wash sale loss disallowed, amortization, accretion, acquisition
premium, bond premium, market discount, market premium, and option premium.
(e) Your 1099-B reflects shares disposed of that were acquired through your employers stock plan. Cost basis associated with these shares may not have been adjusted for any compensation income
that was associated with those shares in the year of acquisition or disposal. Please consult a tax advisor for the rules specific to your grant and plan. Refer to the Supplemental Stock Plan Service
Lot Detail section of this form for additional detail. If there is no adjustment to basis, no Supplemental Stock Plan section will be included.
Amortization, accretion, and similar adjustments to cost basis are not provided for short-term instruments and unit investment trusts.
* 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.
01/17/2022 9001000000 Pages 3 of 6
2021 TAX REPORTING STATEMENT
DENISE ANN VALENTI Account No. Z09-224840 Customer Service: 800-544-6666
Recipient ID No. ***-**-9492 Payer's Fed ID Number: 04-3523567
Summary of 2021 Supplemental Information Not Reported to the IRS
Margin Interest Paid ................................................................................................ 0.00 Currency Realized Gain/Loss (USD) ................................................................................0.00
Tax Exempt Investment Expense ............................................................................ 0.00 Actual Payment Shortfall...................................................................................................0.00
Accrued Interest Paid on Purchases ....................................................................... 0.00 Addition to Basis ...............................................................................................................0.00
Proceeds Investment Expenses .............................................................................. 0.00 Account Fees....................................................................................................................0.00
Severance Tax ........................................................................................................ 0.00 Short Dividends.................................................................................................................0.00
Administrative Expenses ......................................................................................... 0.00 Money Market Realized Gain/Loss...................................................................................0.00
Non-deductible Generic Expenses .......................................................................... 0.00 Short/Long Term Realized Gain/Loss...............................................................................0.00
Deductible Generic Expenses ................................................................................. 0.00 Mortgage Pool Statement (MBS)......................................................................................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.
01/17/2022 9001000000 Pages 4 of 6
2021 SUPPLEMENTAL INFORMATION
DENISE ANN VALENTI Account No. Z09-224840 Customer Service: 800-544-6666
Recipient ID No. ***-**-9492 Payer's Fed ID Number: 04-3523567
Note: This information is not reported to the IRS. It may assist you in tax return preparation.
Detail Information Supplemental Stock Plan Lot Detail
Based on the disposal method you have selected, the lots that appear on your 1099 Supplemental may differ from the lots on the 1099-B.
Short-Term Transactions
Description of Property, Stock or Other Symbol, Cusip
Grant Quantity Date of Date Sold Proceeds Ordinary Income Adjusted Cost or Wash Sale Loss Adjusted Gain/Loss
Type (w) Acquisition (x) or Disposed Reported (y) Other Basis (z) Disallowed
ACCOLADE INC COM, ACCD, 00437E102
QSOP 47.000 02/09/21 02/09/21 2,627.24 1,804.80 2,627.30 0.00 -0.06
Totals 2,627.24 2,627.30
Short-Term Adjusted Realized Gain 0.00
Short-Term Adjusted Realized Loss -0.06
Wash Sale Loss Disallowed 0.00
(w) Grant Type describes the equity award source of the lot you sold this tax year. Please see the Grant Type table for additonal description.
xxxxxx
Grant Type Equity Award Type Acquisition date represents:
DO Deposit Only Shares Deposit Date
NQSOP Non Qualified Stock Option Shares Exercise Date
NQSP Non Qualified ESPP Shares Purchase Date
NSR Non-Incentive SAR (NSR) Exercise Date
QSOP Qualified Stock Option Shares Exercise Date
QSP Qualified ESPP Shares Purchase Date
RSA Restricted Awards Vesting Date
RSU Restricted Units Distribution Date
RSU Performance Units Distribution Date
RSU Total Shareholder Return Units Distribution Date
SAR Stock Appreciation Rights Exercise Date
xxxxxx
xxxxxx
(x) Date of Acquisition is the date that shares were acquired from your Equity Plan and deposited into your brokerage account.
01/17/2022 9001000000 Pages 5 of 6
2021 SUPPLEMENTAL INFORMATION
DENISE ANN VALENTI Account No. Z09-224840 Customer Service: 800-544-6666
Recipient ID No. ***-**-9492 Payer's Fed ID Number: 04-3523567
Note: This information is not reported to the IRS. It may assist you in tax return preparation.
Detail Information Supplemental Stock Plan Lot Detail
Based on the disposal method you have selected, the lots that appear on your 1099 Supplemental may differ from the lots on the 1099-B.
xxxxxx
(y) Fidelity-calculated ordinary income that was reported on the W2 from the year you acquired the shares. Fidelity-calculated ordinary income does not include any adjustments that your company
has made. Fidelity is not responsible for any adjustments that your company may have made to this number.
(z) Adjusted cost or other basis provided may include the following adjustments: ordinary income reported, dividend reinvestment, return of capital/principal and wash sale loss disallowed. In the case
of publicly traded partnerships, the adjusted cost or other basis may not include distributions in excess of taxable income. Please consult your tax advisor and the information on your K-1 to
determine if any adjustment to the cost basis is necessary.
Important Tax Return Document Enclosed.
01/17/2022 9001000000 Pages 6 of 6