Form 1098-Q

2014

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 

2014 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

Name of plan Plan no.

Account number (see instructions) 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 5b 

5c 5d 

5e 5f 

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

2014

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

Name of plan Plan no.

Account number (see instructions) 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 5b 

5c 5d 

5e 5f 

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. 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 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 name, number, and employer identification number. Shows, if 

the contract was purchased under a plan, the name of the plan, the 

plan number, 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, 2014.

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

contract and the date each premium payment was made in 2014.

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

2014

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 

2014 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

Name of plan Plan no.

Account number (see instructions) 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 5b 

5c 5d 

5e 5f 

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 2014 General Instructions for Certain Information 

Returns, and

• the 2014 Instructions for Form 1098-Q.

To order these instructions and additional forms, go 

to www.irs.gov/form1098q or call 1-800-TAX-FORM 

(1-800-829-3676). 

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 February 2, 2015.

File Copy A of this form with the IRS by 

March 2, 2015. 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).