1099-PATR Taxable Distributions Received From Cooperatives

Attention:
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9797

VOID

CORRECTED

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

OMB No. 1545-0118

1 Patronage dividends

$

2016

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.)

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

8 Work opportunity credit

$
$
Form 1099-PATR

9 Patron’s AMT adjustment

$

2nd TIN not. 10 Other credits and deductions

Account number (see instructions)

Cat. No. 14435F

www.irs.gov/form1099patr

Taxable
Distributions
Received From
Cooperatives
For
Internal Revenue
Service Center
File with Form 1096.
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2016 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 or town, state or province, country, ZIP
or foreign postal code, and telephone no.

OMB No. 1545-0118

1 Patronage dividends

$

2016

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

$

For Recipient

5 Redemption of nonqualified
notices and retain allocations

RECIPIENT’S name

$

6 Domestic production
activities deduction

$
7 Investment credit

Street address (including apt. no.)

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

8 Work opportunity credit

$
$
Form 1099-PATR

9 Patron’s AMT adjustment

$

10 Other credits and deductions

Account number (see instructions)

(keep for your records)

www.irs.gov/form1099patr

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

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), adoption taxpayer identification number (ATIN), or
employer identification number (EIN). However, the issuer has reported your
complete identification number to the IRS.
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 didn't 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.
Box 7. This box shows unused investment credits passed through to you by the
cooperative. Use Form 3468, and its instructions, to figure the amount of credit
to which you are entitled.
Box 8. This box shows unused work opportunity credits passed through to you
by the cooperative. Use Form 5884 to figure the amount of credit to which you
are entitled. If your only source of the credit is the cooperative, use Form 3800
instead.
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.
Box 10. This box shows other unused credits and deductions (including
depreciation) passed through to you by the cooperative. For information on how
to report credits, see the instructions for the specific credit form. For information
on how to report deductions, see the instructions for Schedules C and F (Form
1040) and Pub. 946.
Future developments. For the latest information about developments related to
Form 1099-PATR and its instructions, such as legislation enacted after they were
published, go to www.irs.gov/form1099patr.

VOID

CORRECTED

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

OMB No. 1545-0118

1 Patronage dividends

$

2016

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

$
5 Redemption of nonqualified
notices and retain allocations

RECIPIENT’S name

$

6 Domestic production
activities deduction

$
7 Investment credit

Street address (including apt. no.)

$
City or town, state or province, country, and ZIP or foreign postal 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
2016 General
Instructions for
Certain Information
Returns.

$
Form 1099-PATR

www.irs.gov/form1099patr

Department of the Treasury - Internal Revenue Service

Instructions for Payer
To complete Form 1099-PATR, use:
• the 2016 General Instructions for Certain Information
Returns, and
• the 2016 Instructions for Form 1099-PATR.
To order these instructions and additional forms, go to
www.irs.gov/orderforms.
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, 2017.
File Copy A of this form with the IRS by February 28,
2017. If you file electronically, the due date is March 31,
2017. To file electronically, you must have software that
generates a file according to the specifications in Pub.
1220. The 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. See the Instructions for Form 1042-S and Pub.
515.
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). Persons with a hearing or speech disability with
access to TTY/TDD equipment can call 304-579-4827 (not
toll free).