1098-Q Qualifying Longevity Annuity Contract Information

7474

VOID

Version A, Cycle 5
Image Area: 7.3" x 5"; head margin is .5" to top rule

CORRECTED

ISSUER'S name, street address, city or town, state or province, country, ZIP
or foreign postal code, and telephone no.

ISSUER’S federal identification no. OMB No. 1545-XXXX
PARTICIPANT’S taxpayer
identification no.

2014

1a Annuity amount on start date

$

Form

Qualifying
Longevity Annuity
Contract
Information

1098-Q

INTERNAL USE ONLY
DRAFT AS OF
November 3, 2014

PARTICIPANT’S name

1b Annuity start date

2 Check if start date may be
accelerated

3 Total premiums

4 FMV of QLAC

$

$

5a

5b

5c

5d

5e

5f

City or town, state or province, country, and ZIP or foreign postal code
Plan no.

5h August

dd

5j October

dd

5l December

$

$
$

Form 1098-Q

For Privacy Act
and Paperwork
Reduction Act Notice,
see the
2014 General
Instructions for
Certain Information
Returns.

dd

$

5k November
Account number (see instructions)

dd

$

5i September

Name of plan

dd

For
Internal Revenue
Service Center

File with Form 1096.

Street address (including apt. no.)

5g July

Copy A

dd

$

Plan sponsor's employer
identification no.

Cat. No. 67073Z

Do Not Cut or Separate Forms on This Page

www.irs.gov/form1098q

—

Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page

CORRECTED (if checked)
ISSUER'S name, street address, city or town, state or province, country, ZIP
or foreign postal code, and telephone no.

Version A, Cycle 5
Image Area: 7.3" x 5"; head margin is .5" to top rule

ISSUER’S federal identification no. OMB No. 1545-XXXX
PARTICIPANT’S taxpayer
identification no.

2014

1a Annuity amount on start date

$

Form

Qualifying
Longevity Annuity
Contract
Information

1098-Q

INTERNAL USE ONLY
DRAFT AS OF
November 3, 2014
2 If checked, start date may
be accelerated

1b Annuity start date

3 Total premiums

PARTICIPANT’S name

4 FMV of QLAC

$

$

5a

5b

5c

5d

5e

5f

participant

Street address (including apt. no.)

5g July

City or town, state or province, country, and ZIP or foreign postal code
Name of plan

Plan no.

dd

5h August

dd

5j October

dd

5l December

$
$
$

Form 1098-Q

dd

$

5k November
Account number (see instructions)

dd

$

5i September

Copy B

For Payee

dd

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
taxable income
results from this
transaction and the
IRS determines that it
has not been
reported.

$

Plan sponsor's employer
identification no.

(Keep for your records)

www.irs.gov/form1098q

Department of the Treasury - Internal Revenue Service

1098-Q

Version A, Cycle 5
Image Area: 7.3" x 5"; head margin is .5" to top rule

Instructions for Participant
The information on Form 5498-A is submitted to the IRS by the issuer
of your qualified longevity annuity contract (QLAC) to report the status
of the contract. The value of any QLAC purchased after July 1, 2014,
held by your plan (section 401(a), 403(a), 403(b), 408 (other than a
Roth IRA) or eligible governmental plan under section 457(b)), is not
included when calculating the required minimum distribution (RMD)
from your plan

Box 1a. Annuity start date. If the payments have not started,
shows the date on which the annuity is scheduled to start.
Box 2. If checked, shows that the start date may be accelerated.
Box 3. Shows the cumulative total amount of premiums paid for the
contract.
Box 4. Shows the fair market value (FMV) of your QLAC as of
December 31, 2014.

INTERNAL USE ONLY
DRAFT AS OF
November 3, 2014

Account Number. May show an account or other unique number the
issuer assigned to distinguish your account.
Participant'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), adoption
taxpayer identification number (ATIN), or employer identification
number (EIN). However, the issuer has reported your complete
identification number to the IRS.

Plan name, number, and employer identification number. Shows, if
the contract was purchased under a plan, the name of the plan, the
plan number, and the employer identification number (EIN) of the plan
sponsor.
Box 1a. Annuity amount on start date. If the payments have not
started, shows the annuity amount payable on start date.

Boxes 5a–gl. Shows the amount of each premium paid for the
contract and the date each premium payment was made in 2014.

Future developments. For the latest information about developments
related to Form 5498-A and its instructions, such as legislation
enacted after they were published, go to www.irs.gov/form5498a.

1098-Q

VOID

Version A, Cycle 5
Image Area: 7.3" x 5"; head margin is .5" to top rule

CORRECTED

ISSUER'S name, street address, city or town, state or province, country, ZIP
or foreign postal code, and telephone no.

ISSUER’S federal identification no. OMB No. 1545-XXXX
PARTICIPANT’S taxpayer
identification no.

2014

1a Annuity amount on start date

$

Form

Qualifying
Longevity Annuity
Contract
Information

1098-Q

INTERNAL USE ONLY
DRAFT AS OF
November 3, 2014
2 Check if start date may be
accelerated

1b Annuity start date

3 Total premiums

PARTICIPANT’S name

4 FMV of QLAC

$

$

5a

5b

5c

5d

5e

5f

Street address (including apt. no.)

5g July

City or town, state or province, country, and ZIP or foreign postal code
Name of plan

Plan no.

$

Form 1098-Q

5h August

dd

5j October

dd

5l December

dd

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2014 General
Instructions for
Certain Information
Returns.

$

$
5k November

Account number (see instructions)

dd

$

5i September

Copy C

For FILER

dd

$
dd

$

Plan sponsor's employer
identification no.

www.irs.gov/form1098q

Department of the Treasury - Internal Revenue Service

Version A, Cycle 5
Image Area: 7.3" x 5"; head margin is .5" to top rule

Instructions for Issuer
To complete Form 5498-A, use:
• the 2014 General Instructions for Certain Information
Returns, and
• the 2014 Instructions for Forms 5498-A.
To order these instructions and additional forms, go
to www.irs.gov/form5498a 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
participant by February 2, 2015.
File Copy A of this form with the IRS by
March 2, 2015. The IRS does not provide a fill-in form
option.
Need help? If you have questions about reporting on
Form 5498-A, call the information reporting customer
service site toll free at 1-866-455-7438 or 304-263-8700
(not toll free). Persons with a hearing or speech
disability with access to TTY/TDD equipment can call
304-579-4827 (not toll free).

INTERNAL USE ONLY
DRAFT AS OF
November 3, 2014