Form 1099-PATR

Taxable Distributions Received From Cooperatives

Patronage dividends and other distributions from a cooperative.

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Issuer / payer

The business or person that paid and is filing this return. Enter either a business name or an individual name.

Foreign entityIssuer TIN *TIN type *Business name controlFirst 4 significant characters of the business name.Business nameBusiness name (line 2)Individual first nameIndividual middle nameIndividual last nameForeign addressCheck to enter a non-US address (country + province + postal code).Address line 1 *Address line 2City *State (US address)Required for a US address.ZIP code (US address)Province / region (foreign)Country code (foreign)Two-letter ISO country code for a foreign address.Postal code (foreign)Phone number

Recipient / payee

The person or business that received the payment. Enter either a business name or an individual name.

Recipient TINTIN typeBusiness name controlBusiness nameBusiness name (line 2)Individual first nameIndividual middle nameIndividual last nameAdditional recipientForeign addressCheck to enter a non-US address (country + province + postal code).Address line 1 *Address line 2City *State (US address)Required for a US address.ZIP code (US address)Province / region (foreign)Country code (foreign)Two-letter ISO country code for a foreign address.Postal code (foreign)Account numberDistinguishes this recipient if you file more than one of the same form for them.2nd TIN noticeIRS notified you twice within 3 years of an incorrect TIN.

Filing details

Tax year *VoidCorrectedCombined Federal/State Filing — stateElect to have the IRS forward this record to a participating state.

Form 1099-PATR amounts

1Patronage dividends2Nonpatronage distributions3Per-unit retain allocations4Federal income tax withheld5Redemption of nonqualified notices and retain allocations6Section 199A(g) deduction7Qualified payments (Section 199A(b)(7))8Section 199A(a) qualified items9Section 199A(a) SSTB items10Investment credit11Work opportunity credit12Other credits and deductions — Form 884412Other credits and deductions — Form 889612Other credits and deductions — Form 894112Other credits and deductions — Form 893212Other credits and deductions — EPA sulfur regulation deduction12Other credits and deductions — Form 886413Specified cooperative

State & local tax

Add a row per state where tax was withheld. Leave empty if none.

State & local tax #1

State *State ID numberState tax withheldState incomeState distributionLocal tax withheldLocal incomeLocality nameSpecial data entries

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