PDF document
- 1 -

Enlarge image
                                    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.



- 2 -

Enlarge image
            9797                          VOID      CORRECTED
PAYER’S name, street address, city or town, state or province, country, ZIP 1 Patronage dividends         OMB No. 1545-0118
or foreign postal code, and telephone no.                                                                                                   Taxable 
                                                                            $
                                                                            2 Nonpatronage distributions                                    Distributions 
                                                                            $                               2022                     Received From 
                                                                            3 Per-unit retain allocations                                   Cooperatives
                                                                            $                             Form 1099-PATR
PAYER’S TIN                         RECIPIENT’S TIN                         4 Federal income tax withheld   5 Redeemed nonqualified notices Copy A
                                                                            $                             $                                 For 
RECIPIENT’S name                                                            6 Section 199A(g) deduction     7 Qualified payments            Internal Revenue 
                                                                                                              (Section 199A(b)(7))          Service Center
                                                                            $                             $                                 File with Form 1096.
Street address (including apt. no.)                                         8 Section 199A(a) qual. items   9 Section 199A(a) SSTB items    For Privacy Act 
                                                                                                                                            and Paperwork 
                                                                            $                             $                                 Reduction Act 
City or town, state or province, country, and ZIP or foreign postal code    10 Investment credit          11 Work opportunity credit        Notice, see the 
                                                                            $                             $                                 2022 General 
                                                                                                                                            Instructions for 
Account number (see instructions)                   2nd TIN not.            12 Other credits and deductions   13 Specified Coop             Certain Information 
                                                                            $                                                               Returns.
Form 1099-PATR                      Cat. No. 14435F                         www.irs.gov/Form1099PATR        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



- 3 -

Enlarge image
                                                            CORRECTED (if checked)
PAYER’S name, street address, city or town, state or province, country, ZIP 1 Patronage dividends         OMB No. 1545-0118
or foreign postal code, and telephone no.                                                                                                   Taxable 
                                                                            $
                                                                            2 Nonpatronage distributions                                    Distributions 
                                                                            $                               2022                     Received From 
                                                                            3 Per-unit retain allocations                                   Cooperatives
                                                                            $                             Form 1099-PATR
PAYER’S TIN                         RECIPIENT’S TIN                         4 Federal income tax withheld   5 Redeemed nonqualified notices Copy B
                                                                            $                             $                                 For Recipient
RECIPIENT’S name                                                            6 Section 199A(g) deduction     7 Qualified payments 
                                                                                                              (Section 199A(b)(7))          This is important tax 
                                                                                                                                            information and is 
                                                                            $                             $                                 being furnished to the 
Street address (including apt. no.)                                         8 Section 199A(a) qual. items   9 Section 199A(a) SSTB items    IRS. If you are required 
                                                                                                                                            to file a return, a 
                                                                            $                             $                                 negligence penalty or 
City or town, state or province, country, and ZIP or foreign postal code    10 Investment credit          11 Work opportunity credit        other sanction may be 
                                                                                                                                            imposed on you if this 
                                                                            $                             $                                 income is taxable and 
Account number (see instructions)                                           12 Other credits and deductions   13 Specified Coop             the IRS determines that 
                                                                                                                                            it has not been 
                                                                            $                                                               reported.
Form 1099-PATR                      (keep for your records)                 www.irs.gov/Form1099PATR        Department of the Treasury - Internal Revenue Service



- 4 -

Enlarge image
Instructions for Recipient                                                                 Box 6. Shows your share of the cooperative’s section 199A(g) deduction passed 
                                                                                           through to you. The amount must have been designated in a written notice sent 
Distributions you received from a cooperative may be includible in your income.            to you from the cooperative during the section 1382(d) payment period. To claim 
Generally, if you are an individual, report any amounts shown in boxes 1, 2, 3, and 5      the deduction, you must not be a C corporation.
as ordinary income, unless nontaxable, on your income tax return. You must report          Box 7. Shows the amount of qualified payments paid to you on which the 
any redemptions in boxes 2 and 5 as ordinary income to the extent of the stated            cooperative computed its section 199A(g) deduction. If there is an amount in 
dollar value because they were not taxable when issued to you. Amounts shown in            this box and the amount is related to a trade or business for which you are 
boxes 7, 8, and 9 are information needed to compute your section 199A(a)                   claiming a section 199A(a) deduction, you are required to compute a reduction 
deduction. See the instructions for Form 8995 or 8995-A for more information.              to your deduction per section 199A(b)(7).  
Recipient’s taxpayer identification number (TIN). For your protection, this                Box 8. Shows items received and reported in boxes 1, 2, 3, and 5 that may 
form may show only the last four digits of your TIN. However, the issuer has               qualify as qualified items from trades or businesses that are not a specified 
reported your complete TIN to the IRS.                                                     service trade or business (SSTB) for purposes of the section 199A(a) deduction. 
Account number. May show an account or other unique number the payer                       Items relating to SSTBs are reported separately in box 9. 
assigned to distinguish your account.                                                      Box 9. Shows amounts received and reported in boxes 1, 2, 3, and 5 from an 
Box 1.Shows patronage dividends paid to you during the year in cash,        qualified      SSTB that may qualify as qualified items for purposes of the section 199A(a) 
written notices of allocation (at stated dollar value), or other property (not including   deduction. Use Form 8995 or 8995-A to determine your section 199A(a) deduction.
nonqualified allocations). Any dividends paid on (1) property    bought for personal       Box 10. Shows investment credits passed through to you by the cooperative. 
use or (2) capital assets or depreciable property used in  your business are not           Use Form 3468 to compute your allowable credit.
taxable. However, if (2) applies, reduce the basis of the  assets by this amount.          Box 11. Shows work opportunity credits passed through to you. Use Form 5884 
Box 2. Shows nonpatronage distributions paid to you during the year in cash,               or 3800 to compute your allowable credit.
qualified written notices of allocation, or other property, and amounts you                Box 12. Shows other credits and deductions passed through to you. For information 
received in redemption of nonqualified written notices of allocation from                  on how to report credits, see the instructions for the specific credit form.
nonpatronage sources.
Box 3. Shows patronage per-unit retain allocations paid to you during the year             Box 13. If this box is checked, the information reported to you is from a specified 
in cash, qualified per-unit retain certificates, or other property.                        agricultural or horticultural cooperative, as defined in section 199A(g)(4)(A).
Box 4. Shows backup withholding. Generally, a payer must backup withhold if                Future developments. For the latest information about developments related to 
you didn’t furnish your TIN. See Form W-9 and Pub. 505 for more information.               Form 1099-PATR and its instructions, such as legislation enacted after they 
Report this amount on your income tax return as tax withheld.                              were published, go to www.irs.gov/Form1099PATR.
Box 5.Shows amounts you received when you redeemed nonqualified written            notices Free File Program. Go to www.irs.gov/FreeFile to see if you qualify for no-cost 
of allocation and nonqualified per-unit retain allocations from patronage sources.         online federal tax preparation, e-filing, and direct deposit or payment options.



- 5 -

Enlarge image
                                          VOID      CORRECTED
PAYER’S name, street address, city or town, state or province, country, ZIP 1 Patronage dividends         OMB No. 1545-0118
or foreign postal code, and telephone no.                                                                                                   Taxable 
                                                                            $
                                                                            2 Nonpatronage distributions                                    Distributions 
                                                                            $                               2022                     Received From 
                                                                            3 Per-unit retain allocations                                   Cooperatives
                                                                            $                             Form 1099-PATR
PAYER’S TIN                         RECIPIENT’S TIN                         4 Federal income tax withheld   5 Redeemed nonqualified notices Copy C
                                                                            $                             $                                 For Payer
RECIPIENT’S name                                                            6 Section 199A(g) deduction     7 Qualified payments 
                                                                                                              (Section 199A(b)(7))
                                                                                                                                            For Privacy Act 
                                                                            $                             $                                 and Paperwork 
Street address (including apt. no.)                                         8 Section 199A(a) qual. items   9 Section 199A(a) SSTB items    Reduction Act 
                                                                                                                                            Notice, see the 
                                                                            $                             $                                 2022 General 
City or town, state or province, country, and ZIP or foreign postal code    10 Investment credit          11 Work opportunity credit        Instructions for 
                                                                            $                             $                                 Certain Information 
                                                                                                                                            Returns.
Account number (see instructions)                   2nd TIN not.            12 Other credits and deductions   13 Specified Coop
                                                                            $
Form 1099-PATR                            www.irs.gov/Form1099PATR                                          Department of the Treasury - Internal Revenue Service



- 6 -

Enlarge image
Instructions for Payer                                  Filing and furnishing. For filing and furnishing instructions, 
                                                        including due dates, and requesting filing or furnishing 
To complete Form 1099-PATR, use:                        extensions, see the 2022 General Instructions for Certain 
• The 2022 General Instructions for Certain Information Information Returns.
Returns, and                                            Foreign recipient.If the recipient is a nonresident alien, you 
• The 2022 Instructions for Form 1099-PATR.             may have to withhold federal income tax and file Form 
  To get and to order these instructions and additional 1042-S. See the Instructions for  Form 1042-S and Pub. 515.
forms, go to www.irs.gov/EmployerForms.                 Need help?If you have questions about reporting on  Form 
Caution: Because paper forms are scanned during         1099-PATR, call the information reporting customer service 
processing, you cannot file certain Forms 1096, 1097,   site toll free at 866-455-7438 or 304-263-8700 (not toll free). 
1098, 1099, 3921, or 5498 that you print from the IRS   Persons with a hearing or speech disability with access to 
website.                                                TTY/TDD equipment can call 304-579-4827 (not toll free).






PDF file checksum: 2978024284

(Plugin #1/9.12/13.0)