Form 1098-Q - Qualifying Longevity Annuity Contract Information - 2014 Page 3
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1
2
3
4
5
6CORRECTED (if checked)
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 If checked, start date may
1b Annuity start date
Copy B
be accelerated
For Participant
3 Total premiums
4 FMV of QLAC
$
$
PARTICIPANT’S name
5a
5b
This information is
being furnished to
the Internal Revenue
5c
5d
Service.
Street address (including apt. no.)
5e
5f
5g July
dd
5h August
dd
$
$
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
(Keep for your records)
Department of the Treasury - Internal Revenue Service
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