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This form is provided for informational purposes only. Copy A appears in red, similar
to the official IRS form. Do not file copy A downloaded from this website. The official
printed version of this IRS form is scannable, but the online version of it, printed from
this website, is not. A penalty of $50 per information return may be imposed for filing
forms that cannot be scanned.

To order official IRS forms, call 1-800-TAX-FORM (1-800-829-3676) or
Order Information Returns and Employer Returns Online, and we’ll mail you the
scannable forms and other products.

See IRS Publications 1141, 1167, 1179 and other IRS resources for information
about printing these tax forms.
9797                        VOID             CORRECTED
                                                                            1 Patronage dividends              OMB No. 1545-0118
PAYER’S name, street address, city, state, ZIP code, and telephone no.
                                                                                                                                                          Taxable
                                                                            $
                                                                                                                                                    Distributions
                                                                                                                   2009
                                                                            2 Nonpatronage distributions
                                                                                                                                                  Received From
                                                                            $
                                                                                                                                                   Cooperatives
                                                                            3 Per-unit retain allocations
                                                                                                                      1099-PATR
                                                                            $                                  Form
PAYER’S federal identification number   RECIPIENT’S identification number   4 Federal income tax withheld                                                     Copy A
                                                                            $                                                                                   For
                                                                                                                                                   Internal Revenue
RECIPIENT’S name                                                            5 Redemption of nonqualified       6 Domestic production activities
                                                                                                                                                     Service Center
                                                                                                                 deduction
                                                                              notices and retain allocations
                                                                                                                                                  File with Form 1096.
                                                                            $                                  $                                         For Privacy Act
                                                                                                                                                         and Paperwork
                                                                                                               7 Investment credit
Street address (including apt. no.)
                                                                                                                                                          Reduction Act
                                                                                                               $                                         Notice, see the
                                                                            8 Work opportunity credit          9 Patron’s AMT adjustment
City, state, and ZIP code                                                                                                                                 2009 General
                                                                                                                                                        Instructions for
                                                                            $                                  $
                                                                                                                                                           Forms 1099,
                                                              2nd TIN not. 10 Other credits and deductions
Account number (see instructions)
                                                                                                                                                      1098, 3921, 3922,
                                                                            $                                                                          5498, and W-2G.
       1099-PATR
Form                                                                     Cat. No. 14435F                        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)
                                                                            1 Patronage dividends              OMB No. 1545-0118
PAYER’S name, street address, city, state, ZIP code, and telephone no.
                                                                                                                                                          Taxable
                                                                            $
                                                                                                                                                    Distributions
                                                                                                                   2009
                                                                            2 Nonpatronage distributions
                                                                                                                                                  Received From
                                                                            $
                                                                                                                                                   Cooperatives
                                                                            3 Per-unit retain allocations
                                                                                                                      1099-PATR
                                                                            $                                  Form
PAYER’S federal identification number   RECIPIENT’S identification number   4 Federal income tax withheld
                                                                                                                                                                Copy B
                                                                            $                                                                          For Recipient
RECIPIENT’S name                                                            5 Redemption of nonqualified       6 Domestic production activities
                                                                                                                                                           This is important
                                                                                                                 deduction
                                                                              notices and retain allocations
                                                                                                                                                     tax information and is
                                                                                                                                                    being furnished to the
                                                                            $                                  $                                           Internal Revenue
                                                                                                                                                         Service. If you are
                                                                                                               7 Investment credit
Street address (including apt. no.)
                                                                                                                                                            required to file a
                                                                                                                                                       return, a negligence
                                                                                                               $                                             penalty or other
                                                                            8 Work opportunity credit          9 Patron’s AMT adjustment
City, state, and ZIP code                                                                                                                                  sanction may be
                                                                                                                                                   imposed on you if this
                                                                            $                                  $                                    income is taxable and
                                                                                                                                                        the IRS determines
                                                                            10 Other credits and deductions
Account number (see instructions)
                                                                                                                                                       that it has not been
                                                                            $                                                                                       reported.

       1099-PATR                                                   (keep for your records)
Form                                                                                                            Department of the Treasury - Internal Revenue Service
Instructions for Recipient
                                                                                      Box 6. Shows the deduction amount you may take based on your portion of
Distributions you received from a cooperative may be includible in your
                                                                                      patronage dividends or per-unit retain allocations (boxes 1 and 3) attributable
income. Generally, if you are an individual, report any amounts shown in boxes
                                                                                      to qualified production activities income. To claim the deduction amount, this
1, 2, 3, and 5 as income, unless nontaxable, on Schedule F (Form 1040),
                                                                                      amount must have been designated in a written notice sent to you from the
Schedule C (Form 1040), Schedule C-EZ (Form 1040), or Form 4835. See the
                                                                                      cooperative within the payment period under section 1382(d). Enter on the
instructions for Schedule F (Form 1040) and Pub. 225 for more information.
                                                                                      appropriate line of Form 8903.
Account number. May show an account or other unique number the payer
                                                                                      Boxes 7, 8, and 10. These boxes may show unused credits and deductions
assigned to distinguish your account.
                                                                                      passed through to you by the cooperative. In general, if your only source for a
Box 1. Shows patronage dividends paid to you during the year in cash,
                                                                                      credit is from the cooperative, you are not required to complete the source
qualified written notices of allocation (at stated dollar value), or other property
                                                                                      credit form or attach it to Form 3800. Therefore, the following credits may be
(not including nonqualified allocations). Any of the dividends that were paid on
                                                                                      reported directly on Form 3800: the renewable electricity, refined coal, and
(1) property bought for personal use or (2) capital assets or depreciable
                                                                                      Indian coal production credit (Form 8835, Section A); the Indian employment
property used in your business are not taxable. However, if (2) applies, reduce
                                                                                      credit (Form 8845); the low-sulfur diesel fuel production credit (Form 8896);
the basis of the assets by this amount.
                                                                                      and the energy efficient appliance credit (Form 8909). However, for the
Box 2. Shows nonpatronage distributions paid to you during the year in cash,          following credits, complete the forms shown and follow the instructions on the
qualified written notices of allocation, or other property (not including             form for how to report the credit: the investment credit (Form 3468); the
nonqualified written notices of allocation).                                          biodiesel and renewable diesel fuels credit (Form 8864); the work opportunity
Box 3. Shows per-unit retain allocations paid to you during the year in cash,         credit (Form 5884); the renewable electricity, refined coal, and Indian coal
qualified per-unit retain certificates, or other property.                            production credit (Form 8835, Section B); the cellulosic biofuel producer credit
                                                                                      (Form 6478); and the agricultural chemicals security credit (Form 8931). For
Box 4. Shows backup withholding. Generally, a payer must backup withhold at
                                                                                      how to report other credits and deductions that may be passed through to
a 28% rate if you did not furnish your taxpayer identification number to the
                                                                                      you, see the Form 1040 instructions, Form 8896, and Pub. 946.
payer. See Form W-9 for information on backup withholding. Include this
amount on your income tax return as tax withheld.
                                                                                      Box 9. Shows the alternative minimum tax (AMT) adjustment passed through
Box 5. Shows amounts you received when you redeemed nonqualified written
                                                                                      to you by the cooperative. Report this amount on Form 6251 on the
notices of allocation and nonqualified per-unit retain allocations. Because
                                                                                      appropriate line in Part I.
these were not taxable when issued to you, you must report the redemption as
ordinary income to the extent of the stated dollar value.
VOID             CORRECTED
                                                                            1 Patronage dividends              OMB No. 1545-0118
PAYER’S name, street address, city, state, ZIP code, and telephone no.
                                                                                                                                                          Taxable
                                                                            $
                                                                                                                                                    Distributions
                                                                                                                   2009
                                                                            2 Nonpatronage distributions
                                                                                                                                                  Received From
                                                                            $
                                                                                                                                                   Cooperatives
                                                                            3 Per-unit retain allocations
                                                                                                                      1099-PATR
                                                                            $                                  Form
PAYER’S federal identification number   RECIPIENT’S identification number   4 Federal income tax withheld
                                                                                                                                                            Copy C
                                                                            $
                                                                                                                                                                 For
RECIPIENT’S name                                                            5 Redemption of nonqualified       6 Domestic production activities
                                                                                                                                                               Payer
                                                                                                                 deduction
                                                                              notices and retain allocations

                                                                                                                                                       For Privacy Act
                                                                            $                                  $
                                                                                                                                                       and Paperwork
                                                                                                               7 Investment credit
Street address (including apt. no.)
                                                                                                                                                        Reduction Act
                                                                                                               $                                       Notice, see the
                                                                                                                                                        2009 General
                                                                            8 Work opportunity credit          9 Patron’s AMT adjustment
City, state, and ZIP code
                                                                                                                                                      Instructions for
                                                                            $                                  $                                         Forms 1099,
Account number (see instructions)                             2nd TIN not. 10 Other credits and deductions                                          1098, 3921, 3922,
                                                                                                                                                     5498, and W-2G.
                                                                            $
       1099-PATR
Form                                                                                                            Department of the Treasury - Internal Revenue Service
Instructions for Payers
                                                           that generates a file according to the specifications in
General and specific form instructions are provided as
                                                           Pub. 1220, Specifications for Filing Forms 1098, 1099,
separate products. The products you should use to
                                                           3921, 3922, 5498, and W-2G Electronically. IRS does
complete Form 1099-PATR are the 2009 General
                                                           not provide a fill-in form option.
Instructions for Forms 1099, 1098, 3921, 3922, 5498,
and W-2G and the 2009 Instructions for Form                Foreign recipient. If the recipient is a nonresident
1099-PATR. A chart in the general instructions gives a     alien, you may have to withhold federal income tax and
quick guide to which form must be filed to report a        file Form 1042-S, Foreign Person’s U.S. Source
particular payment. To order these instructions and        Income Subject to Withholding. See the Instructions for
additional forms, visit the IRS website at www.irs.gov     Form 1042-S and Pub. 515, Withholding of Tax on
or call 1-800-TAX-FORM (1-800-829-3676).                   Nonresident Aliens and Foreign Entities.
 Caution: Because paper forms are scanned during           Need help? If you have questions about reporting on
 processing, you cannot file Forms 1096, 1098, 1099,       Form 1099-PATR, call the information reporting
 3921, 3922, or 5498 that you print from the IRS           customer service site toll free at 1-866-455-7438 or
 website.                                                  304-263-8700 (not toll free). For TTY/TDD equipment,
                                                           call 304-267-3367 (not toll free).
Due dates. Furnish Copy B of this form to the
recipient by February 1, 2010.
   File Copy A of this form with the IRS by March 1,
2010. If you file electronically, the due date is March
31, 2010. To file electronically, you must have software

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Form 1099-PATR Taxable Distributions Received From Cooperatives

  • 1. Attention: This form is provided for informational purposes only. Copy A appears in red, similar to the official IRS form. Do not file copy A downloaded from this website. The official printed version of this IRS form is scannable, but the online version of it, printed from this website, is not. A penalty of $50 per information return may be imposed for filing forms that cannot be scanned. To order official IRS forms, call 1-800-TAX-FORM (1-800-829-3676) or Order Information Returns and Employer Returns Online, and we’ll mail you the scannable forms and other products. See IRS Publications 1141, 1167, 1179 and other IRS resources for information about printing these tax forms.
  • 2. 9797 VOID CORRECTED 1 Patronage dividends OMB No. 1545-0118 PAYER’S name, street address, city, state, ZIP code, and telephone no. Taxable $ Distributions 2009 2 Nonpatronage distributions Received From $ Cooperatives 3 Per-unit retain allocations 1099-PATR $ Form PAYER’S federal identification number RECIPIENT’S identification number 4 Federal income tax withheld Copy A $ For Internal Revenue RECIPIENT’S name 5 Redemption of nonqualified 6 Domestic production activities Service Center deduction notices and retain allocations File with Form 1096. $ $ For Privacy Act and Paperwork 7 Investment credit Street address (including apt. no.) Reduction Act $ Notice, see the 8 Work opportunity credit 9 Patron’s AMT adjustment City, state, and ZIP code 2009 General Instructions for $ $ Forms 1099, 2nd TIN not. 10 Other credits and deductions Account number (see instructions) 1098, 3921, 3922, $ 5498, and W-2G. 1099-PATR Form Cat. No. 14435F 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. CORRECTED (if checked) 1 Patronage dividends OMB No. 1545-0118 PAYER’S name, street address, city, state, ZIP code, and telephone no. Taxable $ Distributions 2009 2 Nonpatronage distributions Received From $ Cooperatives 3 Per-unit retain allocations 1099-PATR $ Form PAYER’S federal identification number RECIPIENT’S identification number 4 Federal income tax withheld Copy B $ For Recipient RECIPIENT’S name 5 Redemption of nonqualified 6 Domestic production activities This is important deduction notices and retain allocations tax information and is being furnished to the $ $ Internal Revenue Service. If you are 7 Investment credit Street address (including apt. no.) required to file a return, a negligence $ penalty or other 8 Work opportunity credit 9 Patron’s AMT adjustment City, state, and ZIP code sanction may be imposed on you if this $ $ income is taxable and the IRS determines 10 Other credits and deductions Account number (see instructions) that it has not been $ reported. 1099-PATR (keep for your records) Form Department of the Treasury - Internal Revenue Service
  • 4. Instructions for Recipient Box 6. Shows the deduction amount you may take based on your portion of Distributions you received from a cooperative may be includible in your patronage dividends or per-unit retain allocations (boxes 1 and 3) attributable income. Generally, if you are an individual, report any amounts shown in boxes to qualified production activities income. To claim the deduction amount, this 1, 2, 3, and 5 as income, unless nontaxable, on Schedule F (Form 1040), amount must have been designated in a written notice sent to you from the Schedule C (Form 1040), Schedule C-EZ (Form 1040), or Form 4835. See the cooperative within the payment period under section 1382(d). Enter on the instructions for Schedule F (Form 1040) and Pub. 225 for more information. appropriate line of Form 8903. Account number. May show an account or other unique number the payer Boxes 7, 8, and 10. These boxes may show unused credits and deductions assigned to distinguish your account. passed through to you by the cooperative. In general, if your only source for a Box 1. Shows patronage dividends paid to you during the year in cash, credit is from the cooperative, you are not required to complete the source qualified written notices of allocation (at stated dollar value), or other property credit form or attach it to Form 3800. Therefore, the following credits may be (not including nonqualified allocations). Any of the dividends that were paid on reported directly on Form 3800: the renewable electricity, refined coal, and (1) property bought for personal use or (2) capital assets or depreciable Indian coal production credit (Form 8835, Section A); the Indian employment property used in your business are not taxable. However, if (2) applies, reduce credit (Form 8845); the low-sulfur diesel fuel production credit (Form 8896); the basis of the assets by this amount. and the energy efficient appliance credit (Form 8909). However, for the Box 2. Shows nonpatronage distributions paid to you during the year in cash, following credits, complete the forms shown and follow the instructions on the qualified written notices of allocation, or other property (not including form for how to report the credit: the investment credit (Form 3468); the nonqualified written notices of allocation). biodiesel and renewable diesel fuels credit (Form 8864); the work opportunity Box 3. Shows per-unit retain allocations paid to you during the year in cash, credit (Form 5884); the renewable electricity, refined coal, and Indian coal qualified per-unit retain certificates, or other property. production credit (Form 8835, Section B); the cellulosic biofuel producer credit (Form 6478); and the agricultural chemicals security credit (Form 8931). For Box 4. Shows backup withholding. Generally, a payer must backup withhold at how to report other credits and deductions that may be passed through to a 28% rate if you did not furnish your taxpayer identification number to the you, see the Form 1040 instructions, Form 8896, and Pub. 946. payer. See Form W-9 for information on backup withholding. Include this amount on your income tax return as tax withheld. Box 9. Shows the alternative minimum tax (AMT) adjustment passed through Box 5. Shows amounts you received when you redeemed nonqualified written to you by the cooperative. Report this amount on Form 6251 on the notices of allocation and nonqualified per-unit retain allocations. Because appropriate line in Part I. these were not taxable when issued to you, you must report the redemption as ordinary income to the extent of the stated dollar value.
  • 5. VOID CORRECTED 1 Patronage dividends OMB No. 1545-0118 PAYER’S name, street address, city, state, ZIP code, and telephone no. Taxable $ Distributions 2009 2 Nonpatronage distributions Received From $ Cooperatives 3 Per-unit retain allocations 1099-PATR $ Form PAYER’S federal identification number RECIPIENT’S identification number 4 Federal income tax withheld Copy C $ For RECIPIENT’S name 5 Redemption of nonqualified 6 Domestic production activities Payer deduction notices and retain allocations For Privacy Act $ $ and Paperwork 7 Investment credit Street address (including apt. no.) Reduction Act $ Notice, see the 2009 General 8 Work opportunity credit 9 Patron’s AMT adjustment City, state, and ZIP code Instructions for $ $ Forms 1099, Account number (see instructions) 2nd TIN not. 10 Other credits and deductions 1098, 3921, 3922, 5498, and W-2G. $ 1099-PATR Form Department of the Treasury - Internal Revenue Service
  • 6. Instructions for Payers that generates a file according to the specifications in General and specific form instructions are provided as Pub. 1220, Specifications for Filing Forms 1098, 1099, separate products. The products you should use to 3921, 3922, 5498, and W-2G Electronically. IRS does complete Form 1099-PATR are the 2009 General not provide a fill-in form option. Instructions for Forms 1099, 1098, 3921, 3922, 5498, and W-2G and the 2009 Instructions for Form Foreign recipient. If the recipient is a nonresident 1099-PATR. A chart in the general instructions gives a alien, you may have to withhold federal income tax and quick guide to which form must be filed to report a file Form 1042-S, Foreign Person’s U.S. Source particular payment. To order these instructions and Income Subject to Withholding. See the Instructions for additional forms, visit the IRS website at www.irs.gov Form 1042-S and Pub. 515, Withholding of Tax on or call 1-800-TAX-FORM (1-800-829-3676). Nonresident Aliens and Foreign Entities. Caution: Because paper forms are scanned during Need help? If you have questions about reporting on processing, you cannot file Forms 1096, 1098, 1099, Form 1099-PATR, call the information reporting 3921, 3922, or 5498 that you print from the IRS customer service site toll free at 1-866-455-7438 or website. 304-263-8700 (not toll free). For TTY/TDD equipment, call 304-267-3367 (not toll free). Due dates. Furnish Copy B of this form to the recipient by February 1, 2010. File Copy A of this form with the IRS by March 1, 2010. If you file electronically, the due date is March 31, 2010. To file electronically, you must have software