1099-QA Distributions from ABLE Accounts

1A1A

VOID

CORRECTED

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

1 Gross distribution

$
2 Earnings

$
PAYER’S TIN

RECIPIENT’S TIN

3 Basis

$
5 Check if ABLE account
terminated in 2021

RECIPIENT’S name

City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)

Cat. No. 67554X

2021

Distributions
From ABLE
Accounts

Form 1099-QA
4 Program-to-program
transfer
6 Check if the recipient is
not the designated
beneficiary

Copy A
For
Internal Revenue
Service Center
File with Form 1096.
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2021 General
Instructions for
Certain Information
Returns.

Street address (including apt. no.)

Form 1099-QA

OMB No. 1545-2262

www.irs.gov/Form1099QA

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.

1 Gross distribution

$
2 Earnings

$
PAYER’S TIN

RECIPIENT’S TIN

3 Basis

$
5 If checked, ABLE account
terminated in 2021

RECIPIENT’S name

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)

www.irs.gov/Form1099QA

OMB No. 1545-2262

2021

Distributions
From ABLE
Accounts

Form 1099-QA
4 Program-to-program
transfer
6 If this box is checked, the
recipient is not the
designated beneficiary

Copy B
For Recipient
This is important tax
information and is
being furnished to the
IRS. 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 (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), or adoption taxpayer
identification number (ATIN)). However, the payer has reported your complete
TIN 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 2021. 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 return 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 or
1040-SR. 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 2021.
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 Forms 1040 and 1040-SR.
Future developments. For the latest information about developments related to
Form 1099-QA and its instructions, such as legislation enacted after they were
published, go to www.irs.gov/Form1099QA.
FreeFile. Go to www.irs.gov/FreeFile to see if you qualify for no-cost online
federal tax preparation, e-filing, and direct deposit or payment options.

VOID

CORRECTED

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

1 Gross distribution

$
2 Earnings

$
PAYER’S TIN

RECIPIENT’S TIN

3 Basis

$
RECIPIENT’S name

5 Check if ABLE account
terminated in 2021

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

www.irs.gov/Form1099QA

OMB No. 1545-2262

2021

Distributions
From ABLE
Accounts

Form 1099-QA
4 Program-to-program
transfer
6 Check if the recipient is
not the designated
beneficiary

Copy C
For Payer
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2021 General
Instructions for
Certain
Information
Returns.

Department of the Treasury - Internal Revenue Service

Instructions for Payer
To complete Form 1099-QA, use:
• The 2021 General Instructions for Certain Information
Returns, and
• The 2021 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, 2022.

File Copy A of this form with the IRS by February 28,
2022.
Need help? If you have questions about reporting on
Form 1099-QA, 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).