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 may be imposed for filing forms that can’t be scanned. See part O in the current General Instructions for Certain Information Returns for more information about penalties. 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.

Do Not Staple

6969

Form

1096
FILER'S name

Department of the Treasury Internal Revenue Service

Annual Summary and Transmittal of U.S. Information Returns

OMB No. 1545-0108

2012

Street address (including room or suite number)

City, state, and ZIP code Name of person to contact Email address 1 Employer identification number 2 Social security number Telephone number Fax number 3 Total number of forms 4 Federal income tax withheld 5 Total amount reported with this Form 1096

For Official Use Only

$
6 Enter an “X” in only one box below to indicate the type of form being filed.
W-2G 32 1097-BTC 50 1098 81 1098-C 78 1098-E 84 1098-T 83 1099-A 80 1099-B 79 1099-C 85 1099-CAP 73

$
. . . . .
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7 If this is your final return, enter an “X” here
1099-DIV 91 1099-G 86

1099-H 71

1099-INT 92

1099-K 10

1099-LTC 93

1099-MISC 95

1099-OID 96

1099-PATR 97

1099-Q 31

1099-R 98

1099-S 75

1099-SA 94

3921 25

3922 26

5498 28

5498-ESA 72

5498-SA 27

Return this entire page to the Internal Revenue Service. Photocopies are not acceptable.
Under penalties of perjury, I declare that I have examined this return and accompanying documents, and, to the best of my knowledge and belief, they are true, correct, and complete.

Signature ▶

Title ▶

Date ▶

Instructions
Reminder. The only acceptable method of filing information returns with Internal Revenue Service/Information Returns Branch is electronically through the FIRE system. See Pub. 1220, Specifications for Filing Forms 1097, 1098, 1099, 3921, 3922, 5498, 8935, and W-2G Electronically. Purpose of form. Use this form to transmit paper Forms 1097, 1098, 1099, 3921, 3922, 5498, and W-2G to the Internal Revenue Service. Do not use Form 1096 to transmit electronically. For electronic submissions, see Pub. 1220. Caution. If you are required to file 250 or more information returns of any one type, you must file electronically. If you are required to file electronically but fail to do so, and you do not have an approved waiver, you may be subject to a penalty. For more information, see part F in the 2012 General Instructions for Certain Information Returns. Who must file. The name, address, and TIN of the filer on this form must be the same as those you enter in the upper left area of Forms 1097, 1098, 1099, 3921, 3922, 5498, or W-2G. A filer is any person or entity who files any of the forms shown in line 6 above. Enter the filer’s name, address (including room, suite, or other unit number), and TIN in the spaces provided on the form.

When to file. File Form 1096 as follows. • With Forms 1097, 1098, 1099, 3921, 3922, or W-2G, file by February 28, 2013. • With Form 5498, file by May 31, 2013.

Where To File
Send all information returns filed on paper with Form 1096 to the following: If your principal business, office Use the following or agency, or legal residence in three-line address the case of an individual, is located in
Alabama, Arizona, Arkansas, Connecticut, Delaware, Florida, Georgia, Kentucky, Louisiana, Maine, Massachusetts, Mississippi, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Pennsylvania, Rhode