1A1A                        VOID            CORRECTED
PAYER’S name, street address, city or town, state or province, country, ZIP 1 Gross distribution         OMB No. 1545-2262
or foreign postal code, and telephone no.
                                                                                                         Form 1099-QA                    Distributions 
                                                                            $                            (Rev. January 2023)             From ABLE 
                                                                            2 Earnings
                                                                                                         For calendar year               Accounts
                                                                            $                                 20
PAYER’S TIN                         RECIPIENT’S TIN                         3 Basis                      4 Program-to-program            Copy A
                                                                                                           transfer
                                                                            $                                                            For 
RECIPIENT’S name                                                            5 Check if ABLE account      6 Check if the recipient is     Internal Revenue 
                                                                              terminated in the calendar   not the designated            Service Center
                                                                              year reported                beneficiary
                                                                                                                                         File with Form 1096.
Street address (including apt. no.)                                                                                                      For Privacy Act 
                                                                                                                                         and Paperwork 
                                                                                                                                         Reduction Act 
City or town, state or province, country, and ZIP or foreign postal code                                                                 Notice, see the 
                                                                                                                                         current General 
                                                                                                                                         Instructions for 
Account number (see instructions)                                                                                                        Certain Information 
                                                                                                                                         Returns.
Form 1099-QA (Rev. 1-2023)               Cat. No. 67554X                    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

                                                    CORRECTED (if checked)
PAYER’S name, street address, city or town, state or province, country, ZIP 1 Gross distribution         OMB No. 1545-2262
or foreign postal code, and telephone no.
                                                                                                         Form 1099-QA                  Distributions 
                                                                            $                            (Rev. January 2023)           From ABLE 
                                                                            2 Earnings
                                                                                                         For calendar year             Accounts
                                                                            $                                 20
PAYER’S TIN                         RECIPIENT’S TIN                         3 Basis                      4 Program-to-program          Copy B
                                                                                                           transfer
                                                                            $                                                          For Recipient
RECIPIENT’S name                                                            5 Check if ABLE account      6 If this box is checked, the This is important tax 
                                                                              terminated in the calendar   recipient is not the        information and is 
                                                                              year reported                designated beneficiary      being furnished to the 
                                                                                                                                       IRS. If you are required 
Street address (including apt. no.)                                                                                                    to file a return, a 
                                                                                                                                       negligence penalty or 
                                                                                                                                       other sanction may be 
City or town, state or province, country, and ZIP or foreign postal code                                                               imposed on you if this 
                                                                                                                                       income is taxable and 
                                                                                                                                       the IRS determines that 
Account number (see instructions)                                                                                                      it has not been 
                                                                                                                                       reported.
Form 1099-QA (Rev. 1-2023)          (keep for your records)                 www.irs.gov/Form1099QA         Department of the Treasury - Internal Revenue Service

Instructions for Recipient
Recipient’s taxpayer identification number (TIN). For your protection, this       Box 3. Shows your basis in the gross distribution reported in box 1.
form may show only the last four digits of your TIN (social security number       Box 4. This box is checked if a program-to-program transfer was made from 
(SSN), individual taxpayer identification number (ITIN), or adoption taxpayer     this ABLE account to another ABLE account.
identification number (ATIN)). However, the payer has reported your complete      Box 5. This box is checked if the ABLE account was terminated in the calendar 
TIN to the IRS.                                                                   year being reported.
Account number. May show an account or other unique number the payer has          Box 6. The designated beneficiary is the individual named in the document 
assigned to distinguish your account.                                             creating the ABLE account to receive the benefit of the funds in the account. If 
Box 1.Shows the gross distribution paid to you this year from an Achieving a      this box is checked, you are not the designated beneficiary of this ABLE 
Better Life Experience (ABLE) savings account in the calendar year being          account. You and/or the designated beneficiary may be subject to additional 
reported. Gross distribution includes distributions from the ABLE account for     taxes and/or penalties on the box 1 gross distribution. See Form 5329 and its 
both qualified and nonqualified disability expenses. The gross distribution also  separate instructions and the Instructions for Form 1040.
includes amounts distributed that the designated beneficiary intends to roll over Future developments. For the latest information about developments related to 
to another ABLE account, but does not include program-to-program transfers. A     Form 1099-QA and its instructions, such as legislation enacted after they were 
gross distribution also includes a return of excess contributions plus earnings.  published, go to www.irs.gov/Form1099QA.
Box 2. Shows the earnings part of the gross distribution shown in box 1.          Free File Program. Go to www.irs.gov/FreeFile to see if you qualify for no-cost 
Generally, amounts distributed that are used to pay for qualified disability      online federal tax preparation, e-filing, and direct deposit or payment options.
expenses, or rolled over to another ABLE account within 60 days, are not 
included in income. Report taxable amounts as “Other income” on Form 1040 or 
1040-SR. Also see Form 5329 and its separate instructions.

                                         VOID       CORRECTED
PAYER’S name, street address, city or town, state or province, country, ZIP 1 Gross distribution         OMB No. 1545-2262
or foreign postal code, and telephone no.
                                                                                                         Form 1099-QA                    Distributions 
                                                                            $                            (Rev. January 2023)             From ABLE 
                                                                            2 Earnings
                                                                                                         For calendar year               Accounts
                                                                            $                                 20
PAYER’S TIN                         RECIPIENT’S TIN                         3 Basis                      4 Program-to-program        
                                                                                                           transfer                      Copy C
                                                                            $
RECIPIENT’S name                                                            5 Check if ABLE account      6 Check if the recipient is     For Payer
                                                                              terminated in the calendar   not the designated      
                                                                              year reported                beneficiary                   For Privacy Act 
                                                                                                                                         and Paperwork 
Street address (including apt. no.)                                                                                                      Reduction Act 
                                                                                                                                         Notice, see the 
City or town, state or province, country, and ZIP or foreign postal code                                                                 current General 
                                                                                                                                         Instructions for 
                                                                                                                                         Certain 
Account number (see instructions)                                                                                                        Information 
                                                                                                                                         Returns.
Form 1099-QA (Rev. 1-2023)                          www.irs.gov/Form1099QA                                 Department of the Treasury - Internal Revenue Service

Instructions for Payer
To complete Form 1099-QA, use:                           Need help? If you have questions about reporting on 
• The current General Instructions for Certain           Form 1099-QA, call the Technical Services Operation 
Information Returns, and                                 (TSO) toll free at 866-455-7438 or 304-263-8700 (not 
                                                         toll free). Deaf or hard of hearing customers may call 
• The current Instructions for Form 1099-QA.             any of our toll-free numbers using their choice of relay 
To get or to order these instructions, go to             service.
www.irs.gov/EmployerForms.
Filing and furnishing. For filing and furnishing 
instructions, including due dates, and requesting filing 
or furnishing extensions, see the current General 
Instructions for Certain Information Returns.