Form 1099-Patr - Taxable Distributions Received From Cooperatives - 2017 Page 2
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2
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5
6VOID
CORRECTED
9797
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
$
2017
Distributions
2 Nonpatronage distributions
Received From
$
Cooperatives
3 Per-unit retain allocations
1099-PATR
$
Form
Copy A
PAYER’S federal identification number RECIPIENT’S identification number
4 Federal income tax withheld
$
For
Internal Revenue
RECIPIENT’S name
5 Redemption of nonqualified
6 Domestic production
Service Center
notices and retain allocations
activities deduction
$
$
File with Form 1096.
For Privacy Act
Street address (including apt. no.)
7 Investment credit
and Paperwork
$
Reduction Act
8 Work opportunity credit
9 Patron’s AMT adjustment
Notice, see the
City or town, state or province, country, and ZIP or foreign postal code
2017 General
$
$
Instructions for
Account number (see instructions)
2nd TIN not.
10 Other credits and deductions
Certain Information
$
Returns.
1099-PATR
Form
Cat. No. 14435F
Department of the Treasury - Internal Revenue Service
Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page
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