1098-F Fines, Penalties and Other Amounts

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0303

VOID

CORRECTED

FILER’S name, street address, city or town, state or province, country, ZIP
or foreign postal code, and telephone no.

1 Total amount required to be paid OMB No. 1545-2284

$
2 Amount to be paid for
violation or potential violation

$
3 Restitution/remediation
amount
FILER’S TIN

$

PAYER’S TIN

Form

1098-F

(Rev. January 2022)

Fines, Penalties, and
Other Amounts

For calendar year

20
5 Date of order/agreement

Copy A

DRAFT AS OF
September 21, 2021
DO NOT FILE
4 Compliance amount

For
Internal Revenue
Service Center

$

PAYER’S name

6 Court or entity

Street address (including apt. no.)

File with Form 1096.

7 Case number

City or town, state or province, country, and ZIP or foreign postal code

8 Case name or names of parties to suit, order, or agreement
9 Code

Form 1098-F (Rev. 1-2022)

Cat. No. 71382B

www.irs.gov/Form1098F

Do Not Cut or Separate Forms on This Page

—

For Privacy Act and
Paperwork Reduction
Act Notice, see the
current 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 foreign postal code, and telephone no.

1 Total amount required to be paid OMB No. 1545-2284

$
2 Amount to be paid for
violation or potential violation

$
3 Restitution/remediation
amount
FILER’S TIN

PAYER’S TIN

$

Form

1098-F

(Rev. January 2022)

Fines, Penalties, and
Other Amounts

For calendar year

20
5 Date of order/agreement

Copy B

DRAFT AS OF
September 21, 2021
DO NOT FILE
4 Compliance amount

For Payer

$

PAYER’S name

6 Court or entity

Street address (including apt. no.)

7 Case number

City or town, state or province, country, and ZIP or foreign postal code

8 Case name or names of parties to suit, order, or agreement

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

9 Code

Form 1098-F (Rev. 1-2022)

(keep for your records)

www.irs.gov/Form1098F

Department of the Treasury - Internal Revenue Service

Instructions for Payer
This statement has been furnished to you by a government,
governmental entity, or nongovernmental entity regarding a court
order or an 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 5. Shows the date the suit, order, or agreement became binding
under applicable law.
Box 6. Shows the name of the court, or any other entity, that entered
the order or approved the agreement, if applicable.
Box 7. Shows the case number associated with the order or an
agreement, if applicable.
Box 8. Provides a case name or names of the parties to the suit,
order, or agreement.

DRAFT AS OF
September 21, 2021
DO NOT FILE
Box 1. Shows the total amount required to be paid under the suit,
order, or agreement. If $50,000 is reported in box 1, the total amount
was $50,000 or the amount was not identified in the suit, order, or
agreement.
Box 2. Shows the total amount required to be paid in relation to the
violation or potential violation of law as stated in the suit, order, or
agreement. If the amount is unidentified, enter $50,000.

Box 3. Shows the amount identified in the suit, order, or agreement to
be paid as restitution or remediation.
Box 4. Shows the amount identified in the suit, order, or agreement to
be paid to come into compliance with a law.

Box 9. Code.

A—Multiple payments.
B—Multiple payers.
C—Multiple payees.
D—Provision of services or provision of property required.
E—Payment amount not identified.

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.
Free File Program. Go to www.irs.gov/FreeFile to see if you qualify
for no-cost online federal tax preparation, e-filing, and direct deposit
or payment options.

VOID

CORRECTED

FILER’S name, street address, city or town, state or province, country, ZIP
or foreign postal code, and telephone no.

1 Total amount required to be paid OMB No. 1545-2284

$
2 Amount to be paid for
violation or potential violation

$
3 Restitution/remediation
amount
FILER’S TIN

$

PAYER’S TIN

Form

1098-F

(Rev. January 2022)

Fines, Penalties, and
Other Amounts

For calendar year

20
5 Date of order/agreement

Copy C

DRAFT AS OF
September 21, 2021
DO NOT FILE
4 Compliance amount

For Filer

$

PAYER’S name

6 Court or entity

Street address (including apt. no.)

7 Case number

City or town, state or province, country, and ZIP or foreign postal code

8 Case name or names of parties to suit, order, or agreement
9 Code

Form 1098-F (Rev. 1-2022)

www.irs.gov/Form1098F

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

Department of the Treasury - Internal Revenue Service

Instructions for Filer
To complete Form 1098-F, use:
• The current General Instructions for Certain
Information Returns, and
• The current Instructions for Form 1098-F.
To order these instructions and additional forms, go
to www.irs.gov/EmployerForms.
Caution: Because paper forms are scanned during
processing, you cannot file certain Forms 1096, 1097,
1098, 1099, 3921, or 5498 that you download and print
from the IRS website.

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.
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).

DRAFT AS OF
September 21, 2021
DO NOT FILE