Form 1099-Qa - Distributions From Able Accounts - 2016 Page 2

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CORRECTED (if checked)
PAYER’S name, street address, city or town, state or province, country, ZIP or
1 Gross distribution
OMB No. 1545-2262
foreign postal code, and telephone no.
Distributions
2016
$
from ABLE
2 Earnings
Accounts
1099-QA
$
Form
Copy B
PAYER’S federal identification no.
RECIPIENT’S social security number
3 Basis
4 Program-to-program
transfer
For Recipient
$
This is important tax
RECIPIENT’S name
5 If checked, ABLE account
6 If this box is checked, the
information and is
terminated in 2016
recipient is not the
being furnished to the
designated beneficiary
Internal Revenue
Service. If you are
Street address (including apt. no.)
required to file a return,
a negligence penalty or
other sanction may be
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)
it has not been
reported.
1099-QA
(keep for your records)
Form
Department of the Treasury - Internal Revenue Service

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