Form 1098-Q - Qualifying Longevity Annuity Contract Information - 2014 Page 5
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6VOID
CORRECTED
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 C
accelerated
For Issuer
3 Total premiums
4 FMV of QLAC
$
$
PARTICIPANT’S name
5a
5b
For Privacy Act
and Paperwork
Reduction Act
5c
5d
Notice, see the
Street address (including apt. no.)
2014 General
Instructions for
5e
5f
Certain Information
Returns.
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
Department of the Treasury - Internal Revenue Service
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