Form 1099-Qa - Distributions From Able Accounts - 2016 Page 4

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VOID
CORRECTED
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
PAYER’S federal identification no.
RECIPIENT’S social security number
3 Basis
4 Program-to-program
Copy C
transfer
$
For Payer
RECIPIENT’S name
5 Check if ABLE account
6 Check if the recipient is
terminated in 2016
not the designated
For Privacy Act
beneficiary
and Paperwork
Reduction Act
Street address (including apt. no.)
Notice, see the
2016 General
City or town, state or province, country, and ZIP or foreign postal code
Instructions for
Certain
Information
Account number (see instructions)
Returns.
1099-QA
Form
Department of the Treasury - Internal Revenue Service

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