Form 1099-Patr - Taxable Distributions Received From Cooperatives - 2015 Page 3
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1
2
3
4CORRECTED (if checked)
PAYER'S name, street address, city or town, state or province, country, ZIP
1 Patronage dividends
OMB No. 1545-0118
or foreign postal code, and telephone no.
Taxable
$
2015
Distributions
2 Nonpatronage distributions
Received From
$
Cooperatives
3 Per-unit retain allocations
1099-PATR
$
Form
Copy B
PAYER’S federal identification number RECIPIENT’S identification number
4 Federal income tax withheld
$
For Recipient
This is important tax
RECIPIENT’S name
5 Redemption of nonqualified
6 Domestic production
information and is
notices and retain allocations
activities deduction
being furnished to the
$
$
Internal Revenue
Service. If you are
Street address (including apt. no.)
7 Investment credit
required to file a return,
$
a negligence penalty or
other sanction may be
8 Work opportunity credit
9 Patron’s AMT adjustment
City or town, state or province, country, and ZIP or foreign postal code
imposed on you if this
$
$
income is taxable and
the IRS determines that
Account number (see instructions)
10 Other credits and deductions
it has not been
$
reported.
1099-PATR
(keep for your records)
Form
Department of the Treasury - Internal Revenue Service
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