Form 1098-Q - Qualifying Longevity Annuity Contract Information - 2018 Page 2
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67474
VOID
CORRECTED
ISSUER'S name, street address, city or town, state or province, country, ZIP
ISSUER’S TIN
OMB No. 1545-2234
or foreign postal code, and telephone no.
Qualifying
PARTICIPANT’S TIN
Longevity Annuity
2018
Contract
Information
1a Annuity amount on start date
$
1098-Q
Form
2 Check if start date may be
1b Annuity start date
Copy A
accelerated
For
Internal Revenue
3 Total premiums
4 FMV of QLAC
Service Center
$
$
File with Form 1096.
PARTICIPANT’S name
5a January
dd
5b February
dd
$
$
For Privacy Act
5c March
dd
5d April
dd
and Paperwork
$
$
Street address (including apt. no.)
Reduction Act Notice,
see the
5e May
dd
5f June
dd
2018 General
$
$
Instructions for
5g July
dd
5h August
dd
Certain Information
Returns.
$
$
City or town, state or province, country, and ZIP or foreign postal code
5i September
dd
5j October
dd
$
$
Account number (see instructions)
Plan no.
5k November
dd
5l December
dd
$
$
Name of plan
Plan sponsor's EIN
1098-Q
Form
Cat. No. 67073Z
Department of the Treasury - Internal Revenue Service
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Do Not Cut or Separate Forms on This Page
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