Form 1099-PATR Taxable Distributions Received From Cooperatives

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Page 1 of 6 Form 1099-PATR (Page 2 is blank) 3

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CORRECTED
1 Patronage dividends

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

OMB No. 1545-0118

$

10

2 Nonpatronage distributions

$
3 Per-unit retain allocations

$
PAYER’S federal identification number

RECIPIENT’S identification number

Form

1099-PATR

4 Federal income tax withheld

Copy A

$
RECIPIENT’S name

5 Redemption of nonqualified
notices and retain allocations

6 Domestic production activities
deduction

$

$
7 Investment credit

Street address (including apt. no.)

$
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

Do Not Cut or Separate Forms on This Page

—

Taxable
Distributions
Received From
Cooperatives

For
Internal Revenue
Service Center
File with Form 1096.
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2010 General
Instructions for
Certain Information
Returns.

Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page

D

Page 3 of 6 of Form 1099-PATR

3

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CORRECTED (if checked)
PAYER’S name, street address, city, state, ZIP code, and telephone no.

1 Patronage dividends

OMB No. 1545-0118

$

10

2 Nonpatronage distributions

$
3 Per-unit retain allocations

$
PAYER’S federal identification number

RECIPIENT’S identification number

Form

1099-PATR

4 Federal income tax withheld

Copy B

$
RECIPIENT’S name

For Recipient

5 Redemption of nonqualified
notices and retain allocations

6 Domestic production activities
deduction

$

$
7 Investment credit

Street address (including apt. no.)

$
City, state, and ZIP code

Account number (see instructions)

8 Work opportunity credit

9 Patron’s AMT adjustment

$

$

10 Other credits and deductions

$
Form

1099-PATR

(keep for your records)

Taxable
Distributions
Received From
Cooperatives

This is important
tax information and is
being furnished to the
Internal Revenue
Service. If you are
required to file a
return, a negligence
penalty or other
sanction may be
imposed on you if this
income is taxable and
the IRS determines
that it has not been
reported.

Department of the Treasury - Internal Revenue Service

Page 4 of 6 of Form 1099-PATR

3

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Instructions for Recipient
Distributions you received from a cooperative may be includible in your
income. Generally, if you are an individual, report any amounts shown in boxes
1, 2, 3, and 5 as income, unless nontaxable, on Schedule F (Form 1040),
Schedule C (Form 1040), Schedule C-EZ (Form 1040), or Form 4835. See the
instructions for Schedule F (Form 1040) and Pub. 225 for more information.
Account number. May show an account or other unique number the payer
assigned to distinguish your account.
Box 1. Shows patronage dividends paid to you during the year in cash,
qualified written notices of allocation (at stated dollar value), or other property
(not including nonqualified allocations). Any of the dividends that were paid on
(1) property bought for personal use or (2) capital assets or depreciable
property used in your business are not taxable. However, if (2) applies, reduce
the basis of the assets by this amount.
Box 2. Shows nonpatronage distributions paid to you during the year in cash,
qualified written notices of allocation, or other property (not including
nonqualified written notices of allocation).
Box 3. Shows per-unit retain allocations paid to you during the year in cash,
qualified per-unit retain certificates, or other property.
Box 4. Shows backup withholding. Generally, a payer must backup withhold at
a 28% rate if you did not furnish your taxpayer identification number to the
payer. See Form W-9 for information on backup withholding. Include this
amount on your income tax return as tax withheld.
Box 5. Shows amounts you received when you redeemed nonqualified written
notices of allocation and nonqualified per-unit retain allocations. Because
these were not taxable when issued to you, you must report the redemption as
ordinary income to the extent of the stated dollar value.

Box 6. Shows the deduction amount you may take based on your portion of
patronage dividends or per-unit retain allocations (boxes 1 and 3) attributable
to qualified production activities income. To claim the deduction amount, this
amount must have been designated in a written notice sent to you from the
cooperative within the payment period under section 1382(d). Enter on the
appropriate line of Form 8903.
Boxes 7, 8, and 10. These boxes may show unused credits and deductions
passed through to you by the cooperative. In general, if your only source for a
credit is from the cooperative, you are not required to complete the source
credit form or attach it to Form 3800. Therefore, the following credits may be
reported directly on Form 3800: the renewable electricity and Indian coal
production credit (Form 8835, Section A); the Indian employment credit (Form Part I/
8845); the low-sulfur diesel fuel production credit (Form 8896); and the energy
efficient appliance credit (Form 8909). However, for the following credits,
complete the forms shown and follow the instructions on the form for how to
report the credit: the investment credit (Form 3468); the biodiesel and
renewable diesel fuels credit (Form 8864); the work opportunity credit (Form
5884); the renewable electricity and Indian coal production credit (Form 8835, Part II/
Section B); the cellulosic biofuel producer credit (Form 6478); and the
agricultural chemicals security credit (Form 8931). For how to report other
credits and deductions (including depreciation) that may be passed through to
you, see the Form 1040 instructions, Form 8896, and Pub. 946.
Box 9. Shows the alternative minimum tax (AMT) adjustment passed through
to you by the cooperative. Report this amount on Form 6251 on the
appropriate line in Part I.

, refined coal,/

information on/

Page 5 of 6 of Form 1099-PATR

3

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

VOID

CORRECTED

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

1 Patronage dividends

OMB No. 1545-0118

$

10

2 Nonpatronage distributions

$
3 Per-unit retain allocations

$
PAYER’S federal identification number

RECIPIENT’S identification number

Form

1099-PATR

4 Federal income tax withheld

Copy C

$
RECIPIENT’S name

5 Redemption of nonqualified
notices and retain allocations

6 Domestic production activities
deduction

$

$
7 Investment credit

Street address (including apt. no.)

$
City, state, and ZIP code

Account number (see instructions)

Taxable
Distributions
Received From
Cooperatives

8 Work opportunity credit

9 Patron’s AMT adjustment

$

$

2nd TIN not. 10 Other credits and deductions

For
Payer
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2010 General
Instructions for
Certain Information
Returns.

$
Form

1099-PATR

Department of the Treasury - Internal Revenue Service

D

Page 6 of 6 of Form 1099-PATR

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

Instructions for Payers

D

General and specific form instructions are provided as
separate products. The products you should use to
complete Form 1099-PATR are the 2010 General
Instructions for Certain Information Returns and the
2010 Instructions for Form 1099-PATR. A chart in the
general instructions gives a quick guide to which form
must be filed to report a particular payment. To order
these instructions and additional forms, visit the IRS
website at www.irs.gov or call 1-800-TAX-FORM
(1-800-829-3676).
Caution: Because paper forms are scanned during
processing, you cannot file Forms 1096, 1098, 1099,
3921, 3922, or 5498 that you print from the IRS
website.
py B of this form to the
Due dates. Furnish Copy
recipient by January 31, 2011.
File Copy A of this form with the IRS by February 28,
2011. If you
y file electronically, the due date is March
31, 2011. To file electronically, you must have software

that generates a file according to the specifications in
Pub. 1220, Specifications for Filing Forms 1098, 1099,
3921, 3922, 5498, 8935, and W-2G Electronically. IRS
does not provide a fill-in form option.
Foreign recipient. If the recipient is a nonresident
alien, you may have to withhold federal income tax and
file Form 1042-S, Foreign Person’s U.S. Source
Income Subject to Withholding. See the Instructions for
Form 1042-S and Pub. 515, Withholding of Tax on
Nonresident Aliens and Foreign Entities.
Need help? If you have questions about reporting on
Form 1099-PATR, call the information reporting
customer service site toll free at 1-866-455-7438 or
q p
304-263-8700 ((not toll free). For TTY/TDD equipment,
4-579-4827 ((not toll free).
) The hours of operation
p
call 304-579-4827
are Mondayy through
g Friday from 8:30 a.m. to 4:30
p.m., Eastern time.