1099-PATR CORRECTION PREPARATION
Reporting year:
Cooperative legal entity/EIN:
Patron name and account reference:
Original form submission date/receipt ID:
Correction type (Identity/TIN vs. Money amount):

FIELD ADJUSTMENT REVIEW
Box 1 Patronage dividends: [ ] Unchanged [ ] Revised
Box 2 Nonpatronage distributions: [ ] Unchanged [ ] Revised
Box 3 Per-unit retain allocations: [ ] Unchanged [ ] Revised
Box 4 Federal income tax withheld: [ ] Unchanged [ ] Revised
Box 5 Redeemed nonqualified notices: [ ] Unchanged [ ] Revised
Box 6 Section 199A(g) deduction: [ ] Unchanged [ ] Revised
Box 7 Qualified payments: [ ] Unchanged [ ] Revised
Boxes 8-12 Other items/credits: [ ] Unchanged [ ] Revised
Recipient TIN/Name/Address: [ ] Unchanged [ ] Revised

SOURCE DOCUMENTATION
[ ] Internal equity ledger adjustment verified
[ ] Revised written designation of deduction secured
[ ] Explanation of change drafted for patron support

TRANSMISSION AND FURNISHING
[ ] Corrected file formatted with proper indicator
[ ] File accepted by IRS channel (Record Receipt ID: ______)
[ ] Corrected statement furnished to patron
[ ] Master equity ledger tied out to final reported values
Approval signature/date: