3131 VOID CORRECTED

PAYER’S/TRUSTEE’S name, street address, city, state, ZIP code, and telephone number Payments From

Qualified

Education

Programs (Under Sections

529 and 530)

PAYER’S/TRUSTEE’S Federal identification no. RECIPIENT’S social security number 3

RECIPIENT’S name

2

Street address (including apt. no.)

City, state, and ZIP code

Account number (optional)

Form 1099-Q Cat. No. 32223J Department of the Treasury - Internal Revenue Service

Form 1099-Q

OMB No. 1545-1760

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

Basis

Earnings

1 Gross distribution

$

$

$

Copy A

For

Internal Revenue

Service Center

File with Form 1096.

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2003 General

Instructions for

Forms 1099, 1098,

5498, and W-2G.

Check if the recipient is

not the designated

beneficiary

6

4 Trustee-to-trustee

transfer

2003

5

Private State

● Coverdell ESA

Check one:

● Qualified tuition program—

or
CORRECTED (if checked)

RECIPIENT’S social security number 3

RECIPIENT’S name

2

Street address (including apt. no.)

City, state, and ZIP code

Account number (optional)

Form 1099-Q Department of the Treasury - Internal Revenue Service

Form 1099-Q

OMB No. 1545-1760

Basis

Earnings

1 Gross distribution

$

$

$

5

Copy B

(keep for your records)

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.

For Recipient 6 If this box is checked,

the recipient is not

the designated

beneficiary

4 Trustee-to-trustee

transfer

2003

PAYER’S/TRUSTEE’S name, street address, city, state, ZIP code, and telephone number Payments From

Qualified

Education

Programs

(Under Sections

529 and 530)

PAYER’S/TRUSTEE’S Federal identification no.

Private State

● Coverdell ESA

Check one:

● Qualified tuition program—

or

If an FMV amount is shown below, see Pub. 970, Tax

Benefits for Education, for how to figure earnings.
Instructions for Recipient

Box 1. Shows the gross distribution (including in-kind distributions) paid

to you this year from a qualified tuition program (section 529) or a Coverdell

ESA (section 530). This amount is the total of the amounts shown in box

2 and box 3. See Pub. 970 for more information.

Box 2. Shows the earnings part of the gross distribution shown in box 1.

Generally, amounts distributed are included in income unless they are

used to pay for qualified education expenses, transferred between

trustees, or rolled over to another qualified education program within 60

days. Report amounts included in income on the “Other income” line of

Form 1040.

Box 4. This box is checked if you transferred the amount in box 1 from

one education program to another education program in a

trustee-to-trustee transfer. However, this box may not be checked if the

transfer was made from a Coverdell ESA.

Box 5. Shows whether the gross distribution was from a qualified tuition

program (private or state) or from a Coverdell ESA.

Box 6. This box is checked if you are not the designated beneficiary under

the qualified tuition program or a Coverdell ESA.

Box 3. Shows your basis in the gross distribution reported in box 1.

Under a Coverdell ESA, the amount in box 2 is included in income if

there has been a change in the designated beneficiary and the new

designated beneficiary is not a family member or is over age 30 (except

for beneficiaries with special needs).

Also, an additional 10% tax may apply to part or all of any amount

included in income from the Coverdell ESA or qualified tuition program.

See Form 5329, Additional Taxes on Qualified Plans (including IRAs) and

Other Tax-Favored Accounts, and your tax return instructions for

information about how to report any income.

If a final (total) distribution is made from your account and you have

not recovered your contributions, you may have a deductible loss. Claim

any loss on the “Other expenses” line of Schedule A (Form 1040),

Itemized Deductions.

Under a qualified tuition program, the amount in box 2 is included in

income if there has been (a) more than one transfer or rollover within any

12-month period with respect to the same beneficiary, or (b) a change in

the designated beneficiary and the new designated beneficiary is not a

family member.

Caution: For Coverdell ESA distributions (other than earnings on excess

contributions) made during 2003, the payer/trustee is not required to report

amounts in boxes 2 and 3. Instead, the payer/trustee may report the fair

market value of the Coverdell ESA as of December 31, 2003, in the blank

box below boxes 5 and 6. To figure your earnings and basis, use the

Coverdell ESA—Taxable Withdrawals and Basis worksheet in Pub. 970.

Distribution codes. For 2003, the payer/trustee may, but is not required

to, report (in the box below boxes 5 and 6) one of the following codes to

identify the distribution you received: 1—Distributions (including transfers);

2—Excess contributions plus earnings taxable in 2003; 3—Excess

contributions plus earnings taxable in 2002; 4—Disability; 5—Death; 

6— Prohibited transaction.
For Payer

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2003 General

Instructions for

Forms 1099,

1098, 5498, and

W-2G.

Copy C

VOID CORRECTED

RECIPIENT’S social security number 3

RECIPIENT’S name

2

Street address (including apt. no.)

City, state, and ZIP code

Account number (optional)

Form 1099-Q Department of the Treasury - Internal Revenue Service

Form 1099-Q

OMB No. 1545-1760

Basis

Earnings

1 Gross distribution

$

$

$

6 Check if the recipient is

not the designated

beneficiary

4 Trustee-to-trustee

transfer

2003

PAYER’S/TRUSTEE’S name, street address, city, state, ZIP code, and telephone number Payments From

Qualified

Education

Programs (Under Sections

529 and 530)

PAYER’S/TRUSTEE’S Federal identification no.

5

Private State

● Coverdell ESA

Check one:

● Qualified tuition program—

or
Instructions for Payers/Trustees

General and specific form instructions are provided

as separate products. The products you should use

for 2003 are the General Instructions for Forms

1099, 1098, 5498, and W-2G and the separate

specific instructions for each information return you

file. Specific information needed to complete this

form is given in the 2003 Instructions for Form

1099-Q. A chart in the general instructions gives a

quick guide to which form must be filed to report a

particular payment. To order these instructions and

additional forms, call 1-800-TAX-FORM

(1-800-829-3676).

Due dates. Furnish Copy B of this form to the

recipient by February 2, 2004.

File Copy A of this form with the IRS by

March 1, 2004. If you file electronically, the due date

is March 31, 2004.

Caution: Because the IRS processes paper forms by

machine (optical character recognition equipment),

you cannot file with the IRS Forms 1096, 1098, 1099,

or 5498 that you print from the IRS Web Site.