Form 1096 Annual Summary and Transmittal of U.S. Information Retur

Attention:
This form is provided for informational purposes only. Copy A appears in red, similar
to the official IRS form. Do not file copy A downloaded from this website. The official
printed version of this IRS form is scannable, but the online version of it, printed from
this website, is not. A penalty of $50 per information return may be imposed for filing
forms that cannot be scanned.

To order official IRS forms, call 1-800-TAX-FORM (1-800-829-3676) or Order
Information Returns and Employer Returns Online, and we’ll mail you the
scannable forms and other products.
See IRS Publications 1141, 1167, 1179 and other IRS resources for information
about printing these tax forms.

6969

Do Not Staple

OMB No. 1545-0108
Form

Annual Summary and Transmittal of
U.S. Information Returns

1096

Department of the Treasury
Internal Revenue Service

2011

FILER’S name

Street address (including room or suite number)

City, state, and ZIP code
Name of person to contact

For Official Use Only

Telephone number

(
Email address

)

Fax number

(
1 Employer identification number

2 Social security number

)

3 Total number of
forms

6 Enter an “X” in only one box below to indicate the type of form being filed.
W-2G
32

1097-BTC
50

1098
81

1099-K
10

1099-LTC
93

1099-MISC
95

1098-C
78

1099-OID
96

1098-E
84

1099-PATR
97

1098-T
83

5 Total amount reported with this Form 1096

$

$


7 If this is your final return, enter an “X” here

1099-A
80

1099-Q
31

4 Federal income tax withheld

1099-R
98

1099-B
79

1099-C
85

1099-CAP
73

1099-S
75

1099-SA
94

3921
25

1099-DIV
91

3922
26

1099-H
71

1099-INT
92

5498-ESA
72

5498-SA
27

1099-G
86

5498
28

Return this entire page to the Internal Revenue Service. Photocopies are not acceptable.
Under penalties of perjury, I declare that I have examined this return and accompanying documents, and, to the best of my knowledge and belief, they are true,
correct, and complete.

Signature



Title

Instructions
Reminder. The only acceptable method of filing information returns
with Enterprise Computing Center—Martinsburg (ECC—MTB) is
electronically through the FIRE system. See Pub. 1220,
Specifications for Filing Forms 1097, 1098, 1099, 3921, 3922, 5498,
8935, and W-2G Electronically.
Purpose of form. Use this form to transmit paper Forms 1097,
1098, 1099, 3921, 3922, 5498, and W-2G to the Internal Revenue
Service. Do not use Form 1096 to transmit electronically. For
electronic submissions, see Pub. 1220.
Caution. If you are required to file 250 or more information returns of
any one type, you must file electronically. If you are required to file
electronically but fail to do so, and you do not have an approved
waiver, you may be subject to a penalty. For more information, see
part F in the 2011 General Instructions for Certain Information
Returns.
Who must file. The name, address, and TIN of the filer on this form
must be the same as those you enter in the upper left area of Forms
1097, 1098, 1099, 3921, 3922, 5498, or W-2G. A filer is any person
or entity who files any of the forms shown in line 6 above.
Preaddressed Form 1096. If you received a preaddressed Form
1096 from the IRS with Package 1096, use it to transmit paper
Forms 1097, 1098, 1099, 3921, 3922, 5498, and W-2G to the
Internal Revenue Service. If any of the preprinted information is
incorrect, make corrections on the form.



Date



If you are not using a preaddressed form, enter the filer’s name,
address (including room, suite, or other unit number), and TIN in the
spaces provided on the form.
When to file. File Form 1096 as follows.
● With Forms 1097, 1098, 1099, 3921, 3922, or W-2G, file by
February 28, 2012.
● With Form 5498, file by May 31, 2012.

Where To File
Send all information returns filed on paper with Form 1096 to the
following:
If your principal business,
office or agency, or legal
residence in the case of an
individual, is located in

Use the following
three-line address





Alabama, Arizona, Arkansas, Connecticut, Delaware,
Florida, Georgia, Kentucky, Louisiana, Maine,
Massachusetts, Mississippi, New Hampshire,
New Jersey, New Mexico, New York, North Carolina,
Ohio, Pennsylvania, Rhode Island, Texas, Vermont,
Virginia, West Virginia

For more information and the Privacy Act and Paperwork Reduction Act Notice,
see the 2011 General Instructions for Certain Information Returns.

Cat. No. 14400O

Department of the Treasury
Internal Revenue Service Center
Austin, TX 73301

Form

1096

(2011)

Page

Form 1096 (2011)

Alaska, California, Colorado, District of Columbia,
Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas,
Maryland, Michigan, Minnesota, Missouri, Montana,
Nebraska, Nevada, North Dakota, Oklahoma,
Oregon, South Carolina, South Dakota, Tennessee,
Utah, Washington, Wisconsin, Wyoming

Department of the Treasury
Internal Revenue Service Center
Kansas City, MO 64999

If your legal residence or principal place of business is outside the
United States, file with the Department of the Treasury, Internal
Revenue Service Center, Austin, TX 73301.
Transmitting to the IRS. Group the forms by form number and
transmit each group with a separate Form 1096. For example, if you
must file both Forms 1098 and 1099-A, complete one Form 1096 to
transmit your Forms 1098 and another Form 1096 to transmit your
Forms 1099-A. You need not submit original and corrected returns
separately. Do not send a form (1099, 5498, etc.) containing
summary (subtotal) information with Form 1096. Summary
information for the group of forms being sent is entered only in
boxes 3, 4, and 5 of Form 1096.
Box 1 or 2. Complete only if you are not using a preaddressed Form
1096. Make an entry in either box 1 or 2; not both. Individuals not in
a trade or business must enter their social security number (SSN) in
box 2; sole proprietors and all others must enter their employer
identification number (EIN) in box 1. However, sole proprietors who
do not have an EIN must enter their SSN in box 2. Use the same EIN
or SSN on Form 1096 that you use on Forms 1097, 1098, 1099,
3921, 3922, 5498, or W-2G.
Box 3. Enter the number of forms you are transmitting with this Form
1096. Do not include blank or voided forms or the Form 1096 in your
total. Enter the number of correctly completed forms, not the number
of pages, being transmitted. For example, if you send one page of
three-to-a-page Forms 1098 with a Form 1096 and you have
correctly completed two Forms 1098 on that page, enter “2” in box
3 of Form 1096.
Box 4. Enter the total federal income tax withheld shown on the
forms being transmitted with this Form 1096.
Box 5. No entry is required if you are filing Form 1098-T, 1099-A, or
1099-G. For all other forms, enter the total of the amounts from the
specific boxes of the forms listed below.

Form W-2G
Form 1097-BTC
Form 1098
Form 1098-C

Box 1
Boxes 1a, 1b, 1c, and 1d
Boxes 1 and 2
Box 4c

Form 1098-E

Box 1

Form 1099-B

Boxes 2 and 14

Form 1099-C

Box 2

Form 1099-CAP

Box 2

Form 1099-DIV

Boxes 1a, 2a, 3, 8, and 9

Form 1099-H

Box 1

Form 1099-INT
Form 1099-K
Form 1099-LTC

Boxes 1, 3, and 8
Box 1
Boxes 1 and 2

Form 1099-MISC
Form 1099-OID

Boxes 1, 2, 3, 5, 6, 7, 8, 10, 13, and 14
Boxes 1, 2, and 6

Form 1099-PATR

Boxes 1, 2, 3, and 5

Form 1099-Q

Box 1

Form 1099-R

Box 1

Form 1099-S

Box 2

Form 1099-SA
Form 3921
Form 3922

Box 1
Boxes 3 and 4
Boxes 3, 4, and 5

Form 5498
Form 5498-ESA

Boxes 1, 2, 3, 4, 5, 8, 9, 10, 12b, 13a,
and 14a
Boxes 1 and 2

Form 5498-SA

Box 1

Final return. If you will not be required to file Forms 1097, 1098,
1099, 3921, 3922, 5498, or W-2G in the future, either on paper or
electronically, enter an “X” in the “final return” box.
Corrected returns. For information about filing corrections, see the
2011 General Instructions for Certain Information Returns. Originals
and corrections of the same type of return can be submitted using
one Form 1096.

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