1099-QA Distributions from ABLE Accounts

Tax Forms & Publications
Work Request Notification (WRN)/Circulation
Product

Form 1099-QA

Title

Distributions from ABLE Accounts

Tax year 2015
This is the First
work requests.

Processing year 2016
circulation of this product for your review and comments. This circulation can be used to support any necessary

Authority for changes that may impact a Unified Work Request (UWR) (For changes, see Description of Major Changes below)
P.L. 113-295, Division B

Signature of Approving Official

Circulation signature date
Digitally signed by 8GSNB
DN: cn=8GSNB, email=Jason.P.Healey@irs.gov
Date: 2015.03.26 09:27:04 -04'00'

8GSNB

03/26/2015

Description of Major Changes (A description of changes to a form's instructions that may impact a UWR is also included, as applicable)

This is a new form, Form 1099-QA, Distributions from ABLE Accounts. P.L. 113-295, ABLE Act of 2014 allows individuals and families to draw
money set aside in a separate account for the purpose of supporting individuals with disabilities for maintaining health, independence, and quality of
life, without impacting eligibility for other social service programs, such as Medicaid.

Comments: Comments are due 30 days after the date this circulation is signed and issued, unless a different date is specified here:
.
Comments should be sent via email to both the Tax Law Specialist and Reviewer listed below. We will accept comments after the due date, but may not
be able to consider any comments (timely or not) for this revision if implementing the comments would require a late UWR. If we need to make
significant changes based on comments or other new information received, we normally will issue a subsequent circulation of this product; otherwise,
these changes are final unless indicated otherwise in the Description of Major Changes.

Name of Tax Law Specialist Janice Y. Martin

Name of Reviewer Melody G. DeVoe

Email address janice.y.martin@irs.gov

Email address melody.g.devoe@irs.gov

Form 14216 (Rev. 6-2014)

Catalog Number 57440M

publish.no.irs.gov

Department of the Treasury - Internal Revenue Service

Version A, Cycle 3
Dimensions: 7.3" x 3.75"; .5" head margin to top rule

XXXX

VOID

CORRECTED

PAYER’S/TRUSTEE'S name, street address, city or town, state or province, country,
ZIP or foreign postal code, and telephone no.

1 Gross distribution

$

OMB No. 1545-XXXX

2015

Distributions
from ABLE
Accounts

INTERNAL USE ONLY
DRAFT AS OF
March 16, 2015
2 Earnings

PAYER’S/TRUSTEE'S federal identification no. RECIPIENT’S social security number

$

Form 1099-QA

3 Basis

4 Trustee-to-trustee
transfer

$

RECIPIENT’S name

5 Check if ABLE account
terminated in 2015

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

Account number (see instructions)

Cat. No. 67554X

For
Internal Revenue
Service Center

File with Form 1096.
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2015 General
Instructions for
Certain Information
Returns.

Street address (including apt. no.)

Form 1099-QA

6 Check if the recipient is
not the designated
beneficiary

Copy A

www.irs.gov/form1099qa

Department of the Treasury - Internal Revenue Service

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

Version A, Cycle 3
Dimensions: 7.3" x 3.75"; .5" head margin to top rule

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

1 Gross distribution

$
2 Earnings

OMB No. 1545-XXXX

2015

Distributions
from ABLE
Accounts

INTERNAL USE ONLY
DRAFT AS OF
March 16, 2015
PAYER’S/TRUSTEE'S federal identification no. RECIPIENT’S social security number

$

Form 1099-QA

3 Basis

4 Trustee-to-trustee
transfer

$

RECIPIENT’S name

5 If checked, ABLE account
terminated in 2015

Street address (including apt. no.)

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

Account number (see instructions)

Form 1099-QA

(keep for your records)

www.irs.gov/form1099qa

6 If this box is checked, the
recipient is not the
designated beneficiary

Copy B

For Recipient

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.

Department of the Treasury - Internal Revenue Service

Version A, Cycle 3
Dimensions: 7.3" x 3.75"; .5" head margin to top rule

Instructions for Recipient

Box 3. Shows your basis in the gross distribution reported in box 1.
Box 4. This box is checked if a trustee-to-trustee transfer was made from one
ABLE account to another ABLE account.
Box 5. This box is checked if the ABLE account was terminated in 2015.
Box 6. The designated beneficiary is the individual named in the document
creating the trust or custodial account to receive the benefit of the funds in the
account. If this box is checked, you (the recipient) are not the designated
beneficiary of this ABLE account. You may be subject to additional taxes and/or
penalties on the box 1 gross distribution. See Form 5329 and its separate
instructions and the Instructions for Form 1040 (line 21, “Other income”).

INTERNAL USE ONLY
DRAFT AS OF
March 16, 2015

Recipient's taxpayer identification number. For your protection, this form may
show only the last four digits of your SSN, ITIN, or ATIN. However, the payer or
trustee has reported your complete identification number to the IRS.
Account number. May show an account or other unique number the payer has
assigned to distinguish your account.
Box 1. Shows the gross distribution paid to you this year from an Achieving a
Better Life Experience (ABLE) savings account.
Box 2. Shows the earnings part of the gross distribution shown in box 1.
Generally, amounts distributed that are used to pay for qualified disability
expenses, transferred between trustees, or rolled over to another ABLE account
within 60 days, are not included in income. Report taxable amounts as “Other
Income” on Form 1040. Also see Form 5329 and its separate instructions.

Version A, Cycle 3
Dimensions: 7.3" x 3.75"; .5" head margin to top rule

VOID

CORRECTED

PAYER’S/TRUSTEE'S name, street address, city or town, state or province, country,
ZIP or foreign postal code, and telephone no.

1 Gross distribution

$
2 Earnings

OMB No. 1545-XXXX

2015

$

Form 1099-QA

3 Basis

4 Trustee-to-trustee
transfer

Distributions
from ABLE
Accounts

INTERNAL USE ONLY
DRAFT AS OF
March 16, 2015

PAYER’S/TRUSTEE'S federal identification no. RECIPIENT’S social security number

$

RECIPIENT’S name

5 Check if ABLE account
terminated in 2015

Street address (including apt. no.)

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

Account number (see instructions)
Form 1099-QA

www.irs.gov/form1099qa

6 Check if the recipient is
not the designated
beneficiary

Copy C

For Payer
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2015 General
Instructions for
Certain
Information
Returns.

Department of the Treasury - Internal Revenue Service

Version A, Cycle 3
Dimensions: 7.3" x 3.75"; .5" head margin to top rule

s

Instructions for Payer/Trustee

and 5498-QA.

To complete Form 1099-QA, use:
• the 2015 General Instructions for Certain Information
Returns, and
• the 2015 Instructions for Form 1099-QA.
To order these instructions and additional forms, go
to www.irs.gov/form1099qa or call 1-800-TAX-FORM
(1-800-829-3676).
Caution. Because paper forms are scanned during
processing, you cannot file with the IRS Forms 1096,
1097, 1098, 1099, 3921, 3922, or 5498 that you
download from the IRS website.
Due dates. Furnish Copy B of this form to the recipient
by February 1, 2016.

File Copy A of this form with the IRS by February 29,
2016. The IRS does not provide a fill-in form option.
Need help? If you have questions about reporting on
Form 1099-QA, 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).

INTERNAL USE ONLY
DRAFT AS OF
March 16, 2015