Form 1099-PATR Taxable Distributions received From Cooperatives

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Page 1 of 6 Form 1099-PATR (Page 2 is blank) 1

Action

The type and rule above prints on all proofs including departmental
reproduction proofs. MUST be removed before printing.

O.K. to print
T:FP:F

Separation 1 for page 1 of Form 1099-PATR. Prints in
Red (J-6983) Ink.
Separation 2 for page 1 of Form 1099-PATR. Prints in Black Ink.

VOID

Revised proofs
requested

CORRECTED
1 Patronage dividends

PAYER’S name, street address, city, state, ZIP code, and telephone no.

OMB No. 1545-0118

$

2007

2 Nonpatronage distributions

$
3 Per-unit retain allocations

f
o
s
a
6
t
0
f
0
a
2
r
/
D /14
8
0
$

PAYER’S federal identification number

RECIPIENT’S identification number

Form

Street address (including apt. no.)

5 Redemption of nonqualified
notices and retain allocations

6 Domestic production activities
deduction

$

$

7 Investment credit

$

City, state, and ZIP code

Account number (see instructions)

8 Work opportunity credit

9 Patron’s AMT adjustment

$

$

2nd TIN not. 10 Other credits and deductions

$

Form

1099-PATR

Cat. No. 14435F

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—

Taxable
Distributions
Received From
Cooperatives

1099-PATR

4 Federal income tax withheld

$

RECIPIENT’S name

Signature

O.K. to print
Responsible
scan organization

Date

9797

Date

Copy A
For
Internal Revenue
Service Center
File with Form 1096.
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2007 General
Instructions for
Forms 1099, 1098,
5498, and W-2G.

Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page