Form 1099-Q - Payments From Qualified Education Programs (Under Sections 529 And 530) - 2012 Page 2

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3131
VOID
CORRECTED
PAYER’S/TRUSTEE'S name, street address, city, state, ZIP code, and telephone no.
1 Gross distribution
OMB No. 1545-1760
Payments From
Qualified
2012
Education
$
Programs
2 Earnings
(Under Sections
529 and 530)
1099-Q
$
Form
Copy A
PAYER’S/TRUSTEE'S federal identification no. RECIPIENT’S social security number
3 Basis
4 Trustee-to-trustee
transfer
$
For
Internal Revenue
RECIPIENT’S name
5 Check one:
6 Check if the recipient is
Service Center
not the designated
• Qualified tuition program—
beneficiary
File with Form 1096.
or
Private
State
For Privacy Act
Street address (including apt. no.)
• Coverdell ESA
and Paperwork
Reduction Act
Notice, see the
City, state, and ZIP code
2012 General
Instructions for
Account number (see instructions)
Certain Information
Returns.
1099-Q
Form
Cat. No. 32223J
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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