Form 1096 - Annual Summary and Transmittal of U.S. Information Returns

Version A, Cycle 5
Dimensions: 7.3" x 11"

6969

Do Not Staple

Form

1096

OMB No. 1545-0108

Annual Summary and Transmittal of
U.S. Information Returns

Department of the Treasury
Internal Revenue Service

2015

FILER'S name

Street address (including room or suite number)

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

For Official Use Only

Name of person to contact

Telephone number

Email address

Fax number

1 Employer identification number 2 Social security number

3 Total number of forms

4 Federal income tax withheld 5 Total amount reported with this Form 1096

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

1097-BTC
50

1099-LTC
93

1099-MISC
95

1098
81

1098-C
78

1098-E
84

1098-T
83

1099-A
80

$

7 If this is your final return, enter an “X” here
1099-B
79

1099-C
85

1099-CAP
73

1099-DIV
91

.

1099-G
86

.

Internal Use Only
DRAFT AS OF
July 1, 2014
1099-OID
96

1099-PATR
97

1099-Q
31

1099-R
98

1099-S
75

1099-SA
94

3921
25

3922
26

5498
28

5498-ESA
72

.

1099-INT
92

.

.

▶

1099-K
10

5498-SA
27

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.

Future developments. For the latest information about developments
related to Form 1096, such as legislation enacted after it was
published, go to www.irs.gov/form1096.
Reminder. The only acceptable method of filing information returns
with Internal Revenue Service/Information Returns Branch is
electronically through the FIRE system. See Pub. 1220, Specifications
for Electronic Filing of Forms 1097, 1098, 1099, 3921, 3922, 5498, and
W-2G.
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 2015 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.
Enter the filer’s name, address (including room, suite, or other unit
number), and TIN in the spaces provided on the form.

Date ▶

When to file. File Form 1096 as follows.
• With Forms 1097, 1098, 1099, 3921, 3922, or W-2G, file by February
29, 2016.
• With Forms 5498, file by May 31, 2016.

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

Instructions

Title ▶

▲

Signature ▶

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

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

For more information and the Privacy Act and Paperwork Reduction Act Notice,
see the 2015 General Instructions for Certain Information Returns.

Cat. No. 14400O

Form 1096 (2015)

Version A, Cycle 5
Dimensions: 7.3" x 11"

Form 1096 (2015)

Internal Use Only
DRAFT AS OF
July 1, 2014

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. 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
Form 1098-E
Form 1099-B
Form 1099-C
Form 1099-CAP
Form 1099-DIV
Form 1099-INT
Form 1099-K
Form 1099-LTC
Form 1099-MISC
Form 1099-OID
Form 1099-PATR
Form 1099-Q
Form 1099-R
Form 1099-S
Form 1099-SA
Form 3921
Form 3922
Form 5498
Form 5498-ESA
Form 5498-SA

Page 2

Box 1
Box 1
Boxes 1 and 2
Box 4c
Box 1
Boxes 1d and 13
Box 2
Box 2
Boxes 1a, 2a, 3, 8, 9, and 10
Boxes 1, 3, 8, 10, 11, and 13
Box 1a
Boxes 1 and 2
Boxes 1, 2, 3, 5, 6, 7, 8, 10, 13, and 14
Boxes 1, 2, 5, 6, and 8
Boxes 1, 2, 3, and 5
Box 1
Box 1
Box 2
Box 1
Boxes 3 and 4
Boxes 3, 4, and 5
Boxes 1, 2, 3, 4, 5, 8, 9, 10, 12b, 13a,
and 14a
Boxes 1 and 2
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
2015 General Instructions for Certain Information Returns. Originals
and corrections of the same type of return can be submitted using
one Form 1096.