Federal Qualifying Longevity Annuity Contract Information

Qualifying Longevity Annuity Contract Information 
Form 1098-Q (Rev. December 2019)
7474

VOID

CORRECTED

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

OMB No. 1545-2234

PARTICIPANT’S TIN

1a Annuity amount on start date

Qualifying
Form 1098-Q Longevity Annuity
Contract
(Rev. December 2019)
Information
For calendar year
20

$
1b Annuity start date

2 Check if start date may be
accelerated

3 Total premiums

4 FMV of QLAC

$

$

5a January

PARTICIPANT’S name

dd

5b February

dd

5d April

dd

5f June

dd

5h August

dd

5j October

dd

5l December

$

$

5c March

$

Street address (including apt. no.)

$
$
$
$

Form 1098-Q (Rev. 12-2019)

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

dd

$

5k November
Name of plan

dd

$

5i September
Plan number

dd

$

5g July

Account number (see instructions)

dd

$

5e May

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

dd

Copy A

dd

$

Plan sponsor’s EIN

Cat. No. 67073Z

Do Not Cut or Separate Forms on This Page

www.irs.gov/Form1098Q

—

Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page

CORRECTED (if checked)
ISSUER’S name, street address, city or town, state or province, country, ZIP ISSUER’S TIN
or foreign postal code, and telephone no.

OMB No. 1545-2234

PARTICIPANT’S TIN

1a Annuity amount on start date

Qualifying
Form 1098-Q Longevity Annuity
Contract
(Rev. December 2019)
Information
For calendar year
20

$

2 If checked, start date may
be accelerated

1b Annuity start date

3 Total premiums

4 FMV of QLAC

$
5a January

PARTICIPANT’S name

$
dd

$
5c March
5e May

dd

5d April

dd

5f June

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

dd

5h August

dd

5j October

Account number (see instructions)

Plan number

dd

5l December

Form 1098-Q (Rev. 12-2019)

dd
dd

$

$
Name of plan

dd

$

$
5k November

dd

This information is
being furnished
to the IRS.

$

$
5i September

dd

$

$
5g July

5b February

$

$

Street address (including apt. no.)

Copy B
For Participant

dd

$

Plan sponsor’s EIN

(Keep for your records)

www.irs.gov/Form1098Q

Department of the Treasury - Internal Revenue Service

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 held by your plan or IRA
(section 401(a), 403(a), 403(b), or 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.
Participant’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), adoption taxpayer identification
number (ATIN), or employer identification number (EIN)).
However, the issuer has reported your complete TIN to the
IRS.
Plan number, name, and EIN. Shows, if the contract was
purchased under a plan, the number of the plan, the name of
the plan, and the 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,
mm/dd/yyyy.
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. Beginning in 2020, your cumulative total
premiums paid for all QLACs cannot exceed $135,000. Also,
QLACs purchased under an IRA cannot exceed 25% of your
total IRA account balances and QLACs purchased under an
employer’s plan cannot exceed 25% of your account balance
in the plan. If you have paid more than that, contact your
contract issuer.
Box 4. Shows the fair market value (FMV) of your QLAC as of
December 31 of the reporting year.
Boxes 5a–5l. Show the amount of each premium paid for the
contract and the date each premium payment was made in
the reporting year. 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.

VOID

CORRECTED

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

OMB No. 1545-2234

PARTICIPANT’S TIN

1a Annuity amount on start date

Qualifying
Form 1098-Q Longevity Annuity
Contract
(Rev. December 2019)
Information
For calendar year
20

$

2 Check if start date may be
accelerated

1b Annuity start date

3 Total premiums

4 FMV of QLAC

$
5a January

PARTICIPANT’S name

$
dd

$
5c March
5e May

dd

5d April

dd

5f June

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

dd

5h August

dd

5j October

Account number (see instructions)

Plan number

dd

5l December

$
Name of plan

Form 1098-Q (Rev. 12-2019)

dd
dd

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
current General
Instructions for
Certain Information
Returns.

$

$
5k November

dd

$

$
5i September

dd

$

$
5g July

5b February

$

$

Street address (including apt. no.)

Copy C
For Issuer

dd

$
dd

$

Plan sponsor’s EIN

www.irs.gov/Form1098Q

Department of the Treasury - Internal Revenue Service

Instructions for Issuer
To complete Form 1098-Q, use:
• The current General Instructions for Certain
Information Returns, and
• The current 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, or 5498 that you print from the IRS website.
Filing and furnishing. For filing and furnishing
instructions, including due dates, and to request filing or
furnishing extensions, see the current General
Instructions for Certain Information Returns.

To file electronically, you must have software that
generates a file according to the specifications in Pub.
1220. The IRS does not provide a fill-in form option for
Copy A.
Need help? If you have questions about reporting on
Form 1098-Q, 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).