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             7474                        VOID            CORRECTED 
ISSUER’S name, street address, city or town, state or province, country, ZIP  ISSUER’S TIN               OMB No. 1545-2234
or foreign postal code, and telephone no.
                                                                                                                                      Qualifying 
                                                                         PARTICIPANT’S TIN
                                                                                                         Form 1098-Q            Longevity Annuity 
                                                                                                         (Rev. December 2019)         Contract 
                                                                         1a Annuity amount on start date  For calendar year           Information
                                                                         $                                    20
                                                                         1b Annuity start date           2 Check if start date may be Copy A 
                                                                                                         accelerated
                                                                                                                                      For 
                                                                         3 Total premiums                4   FMV of QLAC              Internal Revenue 
                                                                                                                                      Service Center 
                                                                         $                               $                             
PARTICIPANT’S name                                                       5a January            dd        5b February            dd    File with Form 1096. 
                                                                         $                               $
                                                                         5c March              dd        5d April               dd    For Privacy Act 
                                                                                                                                      and Paperwork 
Street address (including apt. no.)                                      $                               $                            Reduction Act 
                                                                         5e May                dd        5f  June               dd    Notice, see the 
                                                                         $                               $                            current General 
                                                                         5g July               dd        5h August              dd    Instructions for 
                                                                                                                                      CertainInformation 
City or town, state or province, country, and ZIP or foreign postal code $                               $                            Returns. 
                                                                         5i  September         dd        5j  October            dd
Account number (see instructions)        Plan number                     $                               $ 
                                                                         5k November           dd        5l  December           dd
                                                                         $                               $ 
Name of plan                             Plan sponsor’s EIN

Form 1098-Q (Rev. 12-2019)               Cat. No. 67073Z                 www.irs.gov/Form1098Q            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



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                                                                 CORRECTED (if checked)
ISSUER’S name, street address, city or town, state or province, country, ZIP  ISSUER’S TIN               OMB No. 1545-2234
or foreign postal code, and telephone no.
                                                                                                                                      Qualifying 
                                                                         PARTICIPANT’S TIN
                                                                                                         Form 1098-Q            Longevity Annuity 
                                                                                                         (Rev. December 2019)         Contract 
                                                                         1a Annuity amount on start date  For calendar year           Information
                                                                         $                                    20
                                                                         1b Annuity start date           2 If checked, start date may Copy B 
                                                                                                         be accelerated
                                                                                                                                       For Participant
                                                                         3 Total premiums                4   FMV of QLAC
                                                                         $                               $
PARTICIPANT’S name                                                       5a January            dd        5b February            dd    This information is 
                                                                         $                               $                            being furnished 
                                                                         5c March              dd        5d April               dd    to the IRS. 
Street address (including apt. no.)                                      $                               $
                                                                         5e May                dd        5f  June               dd
                                                                         $                               $
                                                                         5g July               dd        5h August              dd
City or town, state or province, country, and ZIP or foreign postal code $                               $ 
                                                                         5i  September         dd        5j  October            dd
Account number (see instructions)        Plan number                     $                               $ 
                                                                         5k November           dd        5l  December           dd
                                                                         $                               $ 
Name of plan                             Plan sponsor’s EIN

Form 1098-Q (Rev. 12-2019)               (Keep for your records)         www.irs.gov/Form1098Q            Department of the Treasury - Internal Revenue Service



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Instructions for Participant
The information on this Form 1098-Q is submitted to the IRS      Box 1a. Annuity amount on start date. If the payments have 
by the issuer of your qualifying longevity annuity contract      not started, shows the annuity amount payable on start date. 
(QLAC) to report the status of the contract. Prior to            Box 1b. Annuity start date. If the payments have not started, 
annuitization, the value of any QLAC held by your plan or IRA    shows the date on which the annuity is scheduled to start. The 
(section 401(a), 403(a), 403(b), or 408 (other than a Roth IRA); date reported is shown in the format month, day, and year,  
or eligible governmental plan under section 457(b)) is not       mm/dd/yyyy.
included when calculating the required minimum distribution 
(RMD) from your plan or IRA.                                     Box 2. If checked, shows that the start date may be 
                                                                 accelerated.
You will receive this statement annually beginning with the 
first year in which premiums are paid and ending with the        Box 3. Shows the cumulative total amount of premiums paid 
earlier of the year in which you attain age 85 or die. In the    for the contract. Beginning in 2020, your cumulative total 
event of your death, if the sole beneficiary under the contract  premiums paid for all QLACs cannot exceed $135,000. Also, 
is your surviving spouse, this annual statement will be          QLACs purchased under an IRA cannot exceed 25% of your 
furnished to your surviving spouse until distributions           total IRA account balances and QLACs purchased under an 
commence, or if earlier, the year in which your surviving        employer’s plan cannot exceed 25% of your account balance 
spouse dies.                                                     in the plan. If you have paid more than that, contact your 
                                                                 contract issuer.
If you have questions about your QLAC, contact the issuer 
at the address and phone number shown on the front of the        Box 4. Shows the fair market value (FMV) of your QLAC as of 
form.                                                            December 31 of the reporting year.
Account number. May show an account or other unique              Boxes 5a–5l. Show the amount of each premium paid for the 
number the issuer assigned to distinguish your account.          contract and the date each premium payment was made in 
                                                                 the reporting year. If there is more than one payment per 
Participant’s taxpayer identification number (TIN). For your     month, the box for that month will include the total payments 
protection, this form may show only the last four digits of your for the month and the date of the last payment in the month. 
TIN (social security number (SSN), individual taxpayer 
identification number (ITIN), adoption taxpayer identification   Future developments. For the latest information about 
number (ATIN), or employer identification number (EIN)).         developments related to Form 1098-Q and its instructions, 
However, the issuer has reported your complete TIN to the        such as legislation enacted after they were published, go to 
IRS.                                                             www.irs.gov/Form1098Q. 
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.



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                                         VOID CORRECTED 
ISSUER’S name, street address, city or town, state or province, country, ZIP  ISSUER’S TIN               OMB No. 1545-2234
or foreign postal code, and telephone no.
                                                                                                                                      Qualifying 
                                                                         PARTICIPANT’S TIN
                                                                                                         Form 1098-Q            Longevity Annuity 
                                                                                                         (Rev. December 2019)         Contract 
                                                                         1a Annuity amount on start date  For calendar year           Information
                                                                         $                                    20
                                                                         1b Annuity start date           2 Check if start date may be Copy C 
                                                                                                         accelerated
                                                                                                                                      For Issuer
                                                                         3 Total premiums                4   FMV of QLAC
                                                                         $                               $
PARTICIPANT’S name                                                       5a January            dd        5b February            dd    For Privacy Act 
                                                                         $                               $                            and Paperwork 
                                                                         5c March              dd        5d April               dd    Reduction Act 
                                                                                                                                      Notice, see the 
Street address (including apt. no.)                                      $                               $                            current General 
                                                                         5e May                dd        5f  June               dd    Instructions for 
                                                                         $                               $                            Certain Information 
                                                                         5g July               dd        5h August              dd    Returns.
City or town, state or province, country, and ZIP or foreign postal code $                               $ 
                                                                         5i  September         dd        5j  October            dd
Account number (see instructions)        Plan number                     $                               $ 
                                                                         5k November           dd        5l  December           dd
                                                                         $                               $ 
Name of plan                             Plan sponsor’s EIN

Form 1098-Q (Rev. 12-2019)                    www.irs.gov/Form1098Q                                       Department of the Treasury - Internal Revenue Service



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Instructions for Issuer
To complete Form 1098-Q, use:                               To file electronically, you must have software that 
• The current General Instructions for Certain              generates a file according to the specifications in Pub. 
Information Returns, and                                    1220. The IRS does not provide a fill-in form option for 
                                                            Copy A.
• The current Instructions for Form 1098-Q.
                                                            Need help? If you have questions about reporting on 
To order these instructions and additional forms, go        Form 1098-Q, call the information reporting customer 
to www.irs.gov/Form1098Q.                                   service site toll free at 866-455-7438 or304-263-8700 
Caution: Because paper forms are scanned during             (not toll free). Persons with a hearing or speech 
processing, you cannot file Forms 1096, 1097, 1098,         disability with access to TTY/TDD equipment cancall 
1099, 3921, or 5498 that you print from the IRSwebsite.     304-579-4827 (not toll free). 
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.






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