1098-F Fines, Penalties, and Other Amounts

Attention:
Copy A of this form is provided for informational purposes only. Copy A appears in red,
similar to the official IRS form. The official printed version of Copy A of this IRS form is
scannable, but the online version of it, printed from this website, is not. Do not print and file
copy A downloaded from this website; a penalty may be imposed for filing with the IRS
information return forms that can’t be scanned. See part O in the current General
Instructions for Certain Information Returns, available at www.irs.gov/form1099, for more
information about penalties.
Please note that Copy B and other copies of this form, which appear in black, may be
downloaded and printed and used to satisfy the requirement to provide the information to
the recipient.
To order official IRS information returns, which include a scannable Copy A for filing with
the IRS and all other applicable copies of the form, visit www.IRS.gov/orderforms. Click on
Employer and Information Returns, and we’ll mail you the forms you request and their
instructions, as well as any publications you may order.
Information returns may also be filed electronically using the IRS Filing Information Returns
Electronically (FIRE) system (visit www.IRS.gov/FIRE) or the IRS Affordable Care Act
Information Returns (AIR) program (visit www.IRS.gov/AIR).
See IRS Publications 1141, 1167, and 1179 for more information about printing these tax
forms.

0303

VOID

CORRECTED

FILER’S name, street address, city or town, state or province, country, ZIP or 1 Total amount required to be
paid
foreign postal code, and telephone number

$
2 Restitution/remediation
amount

PAYER’S TIN

2019

3 Compliance amount

4 Date of order/agreement

$

6 Case Number

File with Form 1096.

Street address (including apt. no.)
7 Name or description of matter/suit/agreement
City or town, state or province, country, and ZIP or foreign postal code
8 Code

Form 1098-F

Cat. No. 71382B

Do Not Cut or Separate Forms on This Page

www.irs.gov/Form1098F

—

Copy A
For
Internal Revenue
Service Center

5 Jurisdiction

PAYER’S name

Fines, Penalties, and
Other Amounts

Form 1098-F

$
FILER’S TIN

OMB No. 1545-2284

For Privacy Act and
Paperwork Reduction
Act Notice, see the
2019 General
Instructions for
Certain Information
Returns.

Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page

CORRECTED
FILER’S name, street address, city or town, state or province, country, ZIP or 1 Total amount required to be
paid
foreign postal code, and telephone number

$
2 Restitution/remediation
amount

PAYER’S TIN

2019

3 Compliance amount

4 Date of order/agreement

$

Copy B
For Payer

5 Jurisdiction

PAYER’S name

Fines, Penalties, and
Other Amounts

Form 1098-F

$
FILER’S TIN

OMB No. 1545-2284

6 Case Number
Street address (including apt. no.)
7 Name or description of matter/suit/agreement
City or town, state or province, country, and ZIP or foreign postal code
8 Code

Form 1098-F

(keep for your records)

www.irs.gov/Form1098F

This is important tax
information and is
being furnished to
the IRS.

Department of the Treasury - Internal Revenue Service

Instructions for Payer
This statement has been furnished to you by a government or
governmental entity regarding a court order or agreement with respect to a
violation or potential violation of law. Retain this statement for your
records.
Payer’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.
Box 1. Shows the total amount required to be paid in relation to the violation or
potential violation of law as stated in the court order or agreement.
Box 2. Shows the amount of restitution or remediation required to be paid
as stated in the court order or agreement.
Box 3. Shows the amount identified in the court order or agreement as
required to be paid for purposes of coming into compliance with any law.
Box 4. Shows the date the order was entered by the court or the
agreement was fully executed.
Box 5. Shows the name of the court that entered the order or approved the
agreement, if applicable.

Box 6. Shows the case number associated with the court order or
agreement, if applicable.
Box 7. Provides a name or description to identify the underlying case or
matter to which the court order or agreement relates.
Box 8. Shows one or more of the following codes.
A—Multiple payments.
B—Multiple payers/defendants.
C—Multiple payees.
D—Property required to be acquired, constructed, or transferred under the
court order or agreement.
E—Payment to third party other than government or governmental entity.
F—Paid in full as of time of filing.
G—No payment received as of time of filing.
H—Deferred prosecution agreement.
Future developments. For the latest information about developments related
to Form 1098-F and its instructions, such as legislation enacted after they were
published, go to www.irs.gov/Form1098F.

VOID

CORRECTED

FILER’S name, street address, city or town, state or province, country, ZIP or 1 Total amount required to be
foreign postal code, and telephone number
paid

$
2 Restitution/remediation
amount

$
FILER’S TIN

3 Compliance amount

PAYER’S TIN

OMB No. 1545-2284

2019
Form 1098-F

4 Date of order/agreement

$

Copy C
For Filer

5 Jurisdiction

PAYER’S name

Fines, Penalties, and
Other Amounts

6 Case Number
Street address (including apt. no.)
7 Name or description of matter/suit/agreement
City or town, state or province, country, and ZIP or foreign postal code
8 Code

Form 1098-F

www.irs.gov/Form1098F

For Privacy Act and
Paperwork Reduction
Act Notice, see the
2019 General
Instructions for
Certain Information
Returns.

Department of the Treasury - Internal Revenue Service

Instructions for Filer
To complete Form 1098-F, use:
• The 2019 General Instructions for Certain Information
Returns, and
• The 2019 Instructions for Form 1098-F.
To order these instructions and additional forms, go
to www.irs.gov/Form1098F.
Caution: Because paper forms are scanned during
processing, you cannot file Forms 1096, 1097, 1098,
1099, 3921, or 5498 that you download and print from
the IRS website.
Due dates. Furnish Copy B of this form to the recipient
by January 31, 2020. For information on furnishing Form
1098-F electronically, see the separate Instructions for
Form 1098-F.

File Copy A of this form with the IRS by January 31,
2020. 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-F, 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).