Form 1099-QA Distributions from ABLE Accounts

VOID

1A1A

CORRECTED
1 Gross distribution

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

$
2 Earnings

PAYER’S federal identification no.

RECIPIENT’S social security number

Form 1099-QA

3 Basis

4 Program-to-program
transfer

5 Check if ABLE account
terminated in 2017

Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)
Form 1099-QA

Cat. No. 67554X

2017

$
$
RECIPIENT’S name

OMB No. 1545-2262

www.irs.gov/form1099qa

6 Check if the recipient is
not the designated
beneficiary

Distributions
From ABLE
Accounts
Copy A
For
Internal Revenue
Service Center
File with Form 1096.
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2017 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)
1 Gross distribution

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

$
2 Earnings

PAYER’S federal identification no.

RECIPIENT’S social security number

Form 1099-QA

3 Basis

4 Program-to-program
transfer

5 If checked, ABLE account
terminated in 2017

Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)
Form 1099-QA

(keep for your records)

2017

$
$
RECIPIENT’S name

OMB No. 1545-2262

www.irs.gov/form1099qa

6 If this box is checked, the
recipient is not the
designated beneficiary

Distributions
From ABLE
Accounts
Copy B
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.

Department of the Treasury - Internal Revenue Service

Instructions for Recipient
Recipient's taxpayer identification number. For your protection, this form may
show only the last four digits of your SSN, ITIN, or ATIN. However, the payer
has reported your complete identification number to the IRS.
Account number. May show an account or other unique number the payer has
assigned to distinguish your account.
Box 1. Shows the gross distribution paid to you this year from an Achieving a
Better Life Experience (ABLE) savings account in 2017. Gross distribution
includes distributions from the ABLE account for both qualified and
nonqualified disability expenses. The gross distribution also includes amounts
distributed that the designated beneficiary intends to roll over to another ABLE
account, but does not include program-to-program transfers. A gross
distribution also includes a withdrawal of excess contributions plus earnings.
Box 2. Shows the earnings part of the gross distribution shown in box 1.
Generally, amounts distributed that are used to pay for qualified disability

expenses, or rolled over to another ABLE account within 60 days, are not
included in income. Report taxable amounts as “Other income” on Form 1040.
Also see Form 5329 and its separate instructions.
Box 3. Shows your basis in the gross distribution reported in box 1.
Box 4. This box is checked if a program-to-program transfer was made from
this ABLE account to another ABLE account.
Box 5. This box is checked if the ABLE account was terminated in 2017.
Box 6. The designated beneficiary is the individual named in the document
creating the ABLE account to receive the benefit of the funds in the account. If
this box is checked, you are not the designated beneficiary of this ABLE
account. You and/or the designated beneficiary may be subject to additional
taxes and/or penalties on the box 1 gross distribution. See Form 5329 and its
separate instructions and the Instructions for Form 1040 (line 21, “Other
income”).

VOID

CORRECTED
1 Gross distribution

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

$
2 Earnings

PAYER’S federal identification no.

RECIPIENT’S social security number

Form 1099-QA

3 Basis

4 Program-to-program
transfer

5 Check if ABLE account
terminated in 2017

Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)
Form 1099-QA

2017

$
$
RECIPIENT’S name

OMB No. 1545-2262

www.irs.gov/form1099qa

6 Check if the recipient is
not the designated
beneficiary

Distributions
From ABLE
Accounts
Copy C
For Payer
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2017 General
Instructions for
Certain
Information
Returns.

Department of the Treasury - Internal Revenue Service

Instructions for Payer
To complete Form 1099-QA, use:
• the 2017 General Instructions for Certain Information
Returns, and
• the 2017 Instructions for Form 1099-QA.
To get or to order these instructions, go to
www.irs.gov/form1099qa.
Due dates. Furnish Copy B of this form to the recipient
by January 31, 2018.

File Copy A of this form with the IRS by February 28,
2018.
Need help? If you have questions about reporting on
Form 1099-QA, 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).