Form 1098-F Fines, Penalties, and Other Amounts

Caution: DRAFT—NOT FOR FILING
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DRAFT AS OF
July 31, 2018
DO NOT FILE
0303

VOID

CORRECTED

FILER’S name, street address, city or town, state or province, country, ZIP or 1 Total amount required to be
paid
foreign postal code, and telephone number

$

2 Restitution/remediation
amount

PAYER’S TIN

2019

3 Compliance amount

4 Date of order/agreement

$
5

PAYER’S name

6 Jurisdiction

7 Case Number

Street address (including apt. no.)

8 Name or description of matter/suit/agreement

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

9 Code

Form 1098-F

Cat. No. 71382B

Do Not Cut or Separate Forms on This Page

Fines, Penalties, and
Other Amounts

Form 1098-F

$

FILER’S TIN

OMB No. 1545-XXXX

10 Code

www.irs.gov/Form1098F

—

11 Code

Copy A
For
Internal Revenue
Service Center
File with Form 1096.

For Privacy Act and
Paperwork Reduction
Act Notice, see the
2019 General
Instructions for
Certain Information
Returns.

Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page

CORRECTED
FILER’S name, street address, city or town, state or province, country, ZIP or 1 Total amount required to be
paid
foreign postal code, and telephone number

$
2 Restitution/remediation
amount

PAYER’S TIN

2019

Fines, Penalties, and
Other Amounts

Form 1098-F

$
FILER’S TIN

OMB No. 1545-XXXX

3 Compliance amount

4 Date of order/agreement

DRAFT AS OF
July 31, 2018
DO NOT FILE
$
5

PAYER’S name

6 Jurisdiction

Copy B
For Payer

7 Case Number

Street address (including apt. no.)

8 Name or description of matter/suit/agreement

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

9 Code

Form 1098-F

(keep for your records)

10 Code

www.irs.gov/Form1098F

11 Code

This is important tax
information and is
being furnished to
the IRS.

Department of the Treasury - Internal Revenue Service

Instructions for Payer
This statement has been furnished to you by a government or
governmental entity regarding a court order or agreement with respect to a
violation or potential violation of law. Retain this statement for your
records.
Payer’s taxpayer identification number (TIN). For your protection, this
form may show only the last four digits of your TIN (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 TIN to the IRS.
Box 1. Shows the total amount required to be paid in relation to the violation or
potential violation of law as stated in the court order or agreement.
Box 2. Shows the amount of restitution or remediation required to be paid
as stated in the court order or agreement.
Box 3. Shows the amount identified in the court order or agreement as
required to be paid for purposes of coming into compliance with any law.
Box 4. Shows the date the order was entered by the court or the
agreement was fully executed.
Box 5. Reserved for future use.

Box 6. Shows the name of the court that entered the order or approved the
agreement, if applicable.
Box 7. Shows the case number associated with the court order or
agreement, if applicable.
Box 8. Provides a name or description to identify the underlying case or
matter to which the court order or agreement relates.
Boxes 9–11. Shows one or more of the following codes.
A—Multiple payments.
B—Multiple payers/defendants.
C—Multiple payees.
D—Property required to be acquired, constructed, or transferred under the
court order or agreement.
E—Payment to third party other than government or governmental entity.
F—Paid in full as of time of filing.
G—No payment received as of time of filing.
H—Deferred prosecution agreement.
Future developments. For the latest information about developments related
to Form 1098-F and its instructions, such as legislation enacted after they were
published, go to www.irs.gov/Form1098F.

DRAFT AS OF
July 31, 2018
DO NOT FILE

VOID

CORRECTED

FILER’S name, street address, city or town, state or province, country, ZIP or 1 Total amount required to be
foreign postal code, and telephone number
paid

$
2 Restitution/remediation
amount

3 Compliance amount

PAYER’S TIN

2019

Fines, Penalties, and
Other Amounts

Form 1098-F

$
FILER’S TIN

OMB No. 1545-XXXX

4 Date of order/agreement

Copy C

6 Jurisdiction

For Filer

DRAFT AS OF
July 31, 2018
DO NOT FILE
$
5

PAYER’S name

7 Case Number

Street address (including apt. no.)

8 Name or description of matter/suit/agreement

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

9 Code

Form 1098-F

www.irs.gov/Form1098F

10 Code

11 Code

For Privacy Act and
Paperwork Reduction
Act Notice, see the
2019 General
Instructions for
Certain Information
Returns.

Department of the Treasury - Internal Revenue Service

Instructions for Filer
To complete Form 1098-F, use:
• The 2019 General Instructions for Certain Information
Returns, and
• The 2019 Instructions for Form 1098-F.
To order these instructions and additional forms, go
to www.irs.gov/Form1098F.
Caution: Because paper forms are scanned during
processing, you cannot file Forms 1096, 1097, 1098,
1099, 3921, or 5498 that you download and print from
the IRS website.
Due dates. Furnish Copy B of this form to the recipient
by January 31, 2020. For information on furnishing Form
1098-F electronically, see the separate Specific
Instructions for Form 1098-F.

File Copy A of this form with the IRS by January 31,
2020. 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 for
Copy A.
Need help? If you have questions about reporting on
Form 1098-F, call the information reporting customer
service site toll free at 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).

DRAFT AS OF
July 31, 2018
DO NOT FILE