Form 1098-Q - Qualifying Longevity Annuity Contract Information - 2014 Page 2
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2
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5
6VOID
CORRECTED
7474
ISSUER'S name, street address, city or town, state or province, country, ZIP
ISSUER’S federal identification no.
OMB No. 1545-2234
or foreign postal code, and telephone no.
Qualifying
PARTICIPANT’S taxpayer
Longevity Annuity
2014
identification no.
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
5b
For Privacy Act
5c
5d
and Paperwork
Street address (including apt. no.)
Reduction Act Notice,
see the
5e
5f
2014 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
$
$
Name of plan
Plan no.
5k November
dd
5l December
dd
$
$
Account number (see instructions)
Plan sponsor's employer
identification no.
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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