Form 1098-Q

2016

Cat. No. 67073Z

Qualifying 

Longevity Annuity 

Contract 

Information

Copy A 

For 

Internal Revenue 

Service Center 

File with Form 1096.

Department of the Treasury - Internal Revenue Service

OMB No. 1545-2234

For Privacy Act 

and Paperwork 

Reduction Act Notice, 

see the 

2016 General 

Instructions for 

Certain Information 

Returns. 

7474 VOID CORRECTED 

ISSUER'S name, street address, city or town, state or province, country, ZIP 

or foreign postal code, and telephone no.

PARTICIPANT’S name 

Street address (including apt. no.) 

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

Account number (see instructions) Plan no.

Name of plan Plan sponsor's employer 

identification no. 

ISSUER’S federal identification no. 

PARTICIPANT’S taxpayer 

identification no.

1a Annuity amount on start date

$ 

1b Annuity start date 2 Check if start date may be 

accelerated

3 Total premiums

$ 

4 FMV of QLAC

$

5a January

$

dd 5b February

$

dd

5c March

$

dd 5d April

$

dd

5e May

$

dd 5f June

$

dd

5g July 

$ 

dd 5h August

$ 

dd

5i September

$ 

dd 5j October

$ 

dd

5k November

$ 

dd 5l December

$ 

dd

Form 1098-Q www.irs.gov/form1098q

Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page
 

Form 1098-Q

2016

Qualifying 

Longevity Annuity 

Contract 

Information

Copy B 

 For Participant 

Department of the Treasury - Internal Revenue Service

This information is 

being furnished to 

the Internal Revenue 

Service. 

OMB No. 1545-2234

CORRECTED (if checked)

ISSUER'S name, street address, city or town, state or province, country, ZIP 

or foreign postal code, and telephone no.

PARTICIPANT’S name 

Street address (including apt. no.) 

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

Account number (see instructions) Plan no.

Name of plan Plan sponsor's employer 

identification no. 

ISSUER’S federal identification no. 

PARTICIPANT’S taxpayer 

identification no.

1a Annuity amount on start date

$ 

1b Annuity start date 2 If checked, start date may 

be accelerated

3 Total premiums

$ 

4 FMV of QLAC

$

5a January

$

dd 5b February

$

dd

5c March

$

dd 5d April

$

dd

5e May

$

dd 5f June

$

dd

5g July 

$ 

dd 5h August

$ 

dd

5i September

$ 

dd 5j October

$ 

dd

5k November

$ 

dd 5l December

$ 

dd

Form 1098-Q (Keep for your records) www.irs.gov/form1098q
Instructions for Participant

The information on this Form 1098-Q is submitted to the IRS 

by the issuer of your qualifying longevity annuity contract 

(QLAC) to report the status of the contract. Prior to 

annuitization, the value of any QLAC purchased after July 1, 

2014, held by your plan or IRA (section 401(a), 403(a), 403(b), 

408 (other than a Roth IRA) or eligible governmental plan 

under section 457(b)), is not included when calculating the 

required minimum distribution (RMD) from your plan or IRA.

You will receive this statement annually beginning with the 

first year in which premiums are paid and ending with the 

earlier of the year in which you attain age 85 or die. In the 

event of your death, if the sole beneficiary under the contract 

is your surviving spouse, this annual statement will be 

furnished to your surviving spouse until distributions 

commence, or if earlier, the year in which your surviving 

spouse dies.

If you have questions about your QLAC, contact the issuer 

at the address and phone number shown on the front of the 

form.

Account number. May show an account or other unique 

number the issuer assigned to distinguish your account 

(QLAC).

Participant's taxpayer 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.

Plan number, name, and employer identification number. 

Shows, if the contract was purchased under a plan, the 

number of the plan, the name of the plan, and the employer 

identification number (EIN) of the plan sponsor.

Box 1a. Annuity amount on start date. If the payments have 

not started, shows the annuity amount payable on start date. 

Box 1b. Annuity start date. If the payments have not started, 

shows the date on which the annuity is scheduled to start. The 

date reported is shown in the format month, day, and year 

(mmddyyyy).

Box 2. If checked, shows that the start date may be 

accelerated.

Box 3. Shows the cumulative total amount of premiums paid 

for the contract.

Box 4. Shows the fair market value (FMV) of your QLAC as of 

December 31, 2016.

Boxes 5a–5l. Shows the amount of each premium paid for the 

contract and the date each premium payment was made in 

2016. If there is more than one payment per month, the box 

for that month will include the total payments for the month 

and the date of the last payment in the month. 

Future developments. For the latest information about 

developments related to Form 1098-Q and its instructions, 

such as legislation enacted after they were published, go to 

www.irs.gov/form1098q.
 

Form 1098-Q

2016

Qualifying 

Longevity Annuity 

Contract 

Information

Copy C 

For Issuer 

Department of the Treasury - Internal Revenue Service

OMB No. 1545-2234

For Privacy Act 

and Paperwork 

Reduction Act 

Notice, see the 

2016 General 

Instructions for 

Certain Information 

Returns.

VOID CORRECTED 

ISSUER'S name, street address, city or town, state or province, country, ZIP 

or foreign postal code, and telephone no.

PARTICIPANT’S name 

Street address (including apt. no.) 

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

Account number (see instructions) Plan no.

Name of plan Plan sponsor's employer 

identification no. 

ISSUER’S federal identification no. 

PARTICIPANT’S taxpayer 

identification no.

1a Annuity amount on start date

$ 

1b Annuity start date 2 Check if start date may be 

accelerated

3 Total premiums

$ 

4 FMV of QLAC

$

5a January

$

dd 5b February

$

dd

5c March

$

dd 5d April

$

dd

5e May

$

dd 5f June

$

dd

5g July 

$ 

dd 5h August

$ 

dd

5i September

$ 

dd 5j October

$ 

dd

5k November

$ 

dd 5l December

$ 

dd

Form 1098-Q www.irs.gov/form1098q
Instructions for Issuer

To complete Form 1098-Q, use:

• the 2016 General Instructions for Certain Information 

Returns, and

• the 2016 Instructions for Form 1098-Q.

To order these instructions and additional forms, go 

to www.irs.gov/form1098q. 

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 

participant by January 31, 2017.

File Copy A of this form with the IRS by February 28, 

2017. The IRS does not provide a fill-in form option.

Need help? If you have questions about reporting on

Form 1098-Q, 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).