Form 1099-PATR Taxable Distributions Received From Cooperatives

Attention:
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9797

VOID

CORRECTED

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

OMB No. 1545-0118

1 Patronage dividends

$

2012

2 Nonpatronage distributions

$
3 Per-unit retain allocations

$
PAYER’S federal identification number RECIPIENT’S identification number

Form

1099-PATR
Copy A

4 Federal income tax withheld

$
5 Redemption of nonqualified
notices and retain allocations

RECIPIENT’S name

$

6 Domestic production
activities deduction

$
7 Investment credit

Street address (including apt. no.)

$
8 Work opportunity credit

City, state, and ZIP code

$
Account number (see instructions)

9 Patron’s AMT adjustment

$

2nd TIN not. 10 Other credits and deductions

$
Form 1099-PATR

Cat. No. 14435F

Taxable
Distributions
Received From
Cooperatives
For
Internal Revenue
Service Center
File with Form 1096.
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2012 General
Instructions for
Certain Information
Returns.

Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page

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

OMB No. 1545-0118

1 Patronage dividends

$

2012

2 Nonpatronage distributions

$
3 Per-unit retain allocations

$
PAYER’S federal identification number RECIPIENT’S identification number

Form

1099-PATR
Copy B

4 Federal income tax withheld

$
RECIPIENT’S name

For Recipient

$

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.

(keep for your records)

Department of the Treasury - Internal Revenue Service

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

8 Work opportunity credit

$
Account number (see instructions)
Form 1099-PATR

Taxable
Distributions
Received From
Cooperatives

9 Patron’s AMT adjustment

$

10 Other credits and deductions

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), or Form 4835. See the Instructions for Schedule F (Form 1040) and
Pub. 225 for more information.
Recipient's identification number. For your protection, this form may show
only the last four digits of your social security number (SSN), individual taxpayer
identification number (ITIN), or adoption taxpayer identification number (ATIN).
However, the issuer has reported your complete identification number to the
IRS, and, where applicable, to state and/or local governments.
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 dividends 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 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. Generally, 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 work opportunity credit (Form 5884); the
small ethanol and cellulosic biofuel producer credits (Form 6478); the renewable
electricity production credit (Form 8835, Part I); the Indian employment credit
(Form 8845); 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
renewable electricity, refined coal, and Indian coal production credit (Form 8835,
Part II); the biodiesel and renewable diesel fuels credit (Form 8864); and the
agricultural chemicals security credit (Form 8931). For information on how to
report other credits and deductions (including depreciation) that may be passed
through to you, see the instructions for Schedules C and F (Form 1040) 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.

VOID

CORRECTED

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

OMB No. 1545-0118

1 Patronage dividends

$

2012

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

8 Work opportunity credit

$
Account number (see instructions)

Taxable
Distributions
Received From
Cooperatives

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
2012 General
Instructions for
Certain Information
Returns.

$
Form 1099-PATR

Department of the Treasury - Internal Revenue Service

Instructions for Payer
General and specific form instructions are provided as
separate products. The products you should use to
complete Form 1099-PATR are the 2012 General
Instructions for Certain Information Returns and the 2012
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 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, 1097, 1098, 1099,
3921, 3922, or 5498 that you print from the IRS website.
Due dates. Furnish Copy B of this form to the recipient by
January 31, 2013.
File Copy A of this form with the IRS by February 28,
2013. If you file electronically, the due date is April 1, 2013.
To file electronically, you must have software that

generates a file according to the specifications in Pub.
1220, Specifications for Filing Forms 1097, 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 304-263-8700 (not toll
free). For TTY/TDD equipment, call 304-579-4827 (not toll
free). The hours of operation are Monday through Friday
from 8:30 a.m. to 4:30 p.m., Eastern time.