Employee contributions

or insurance premiums

9898 VOID CORRECTED

PAYER’S name, street address, city, state, and ZIP code 1 Gross distribution OMB No. 1545-0119 Di

Pen

$

2a Taxable amount

$

Total

distribution

Taxable amount

not determined

2b 

RECIPIENT’S identification

number

PAYER’S Federal identification

number

3 Capital gain (included

in box 2a)

4 Federal income tax

withheld

I

$ $

RECIPIENT’S name Net unrealized

appreciation in

employer’s securities

5 6 

$ $

IRA/

SEP/

SIMPLE

Distribution

code(s)

Street address (including apt. no.) 7 8 Other

%

Your percentage of total

distribution

City, state, and ZIP code 9a

%

Account number (see instructions) 10 State tax withheld 11 State/Payer’s state no.

$

13 Local tax withheld 14 Name of locality

$

Form 1099-R Department of the Treasury - In

F

Cat. No. 14436Q

1

1

$

$

$

$

$ $

$

Form 1099-R

9b Total employee contributions

$

Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms 

2005
Employee contributions

or insurance premiums

VOID CORRECTED

PAYER’S name, street address, city, state, and ZIP code 1 Gross distribution Di

Pen

$

2a Taxable amount

$

Total

distribution

Taxable amount

not determined

2b

RECIPIENT’S identification

number

PAYER’S Federal identification

number

3 Capital gain (included

in box 2a)

4 Federal income tax

withheld

$ $

RECIPIENT’S name Net unrealized

appreciation in

employer’s securities

5 6

$ $

Distribution

code(s)

Street address (including apt. no.) 7 8 Other

%

City, state, and ZIP code

Account number (see instructions) 10 State tax withheld 11 State/Payer’s state no.

$

13 Local tax withheld 14 Name of locality

$

Form 1099-R Department of the Treasury - In

1

1

$

$

$

$

$

$

$

OMB No. 1545-0119

Your percentage of total

distribution

9a

%

Form 1099-R

9b Total employee contributions

$

IRA/

SEP/

SIMPLE

2005
Employee contributions

or insurance premiums

CORRECTED (if checked)

PAYER’S name, street address, city, state, and ZIP code 1 Gross distribution Di

Pen

$

2a Taxable amount

$

Total

distribution

Taxable amount

not determined

2b

RECIPIENT’S identification

number

PAYER’S Federal identification

number

3 Capital gain (included

in box 2a)

4 Federal income tax

withheld

$ $

RECIPIENT’S name Net unrealized

appreciation in

employer’s securities

5 6

$ $

Distribution

code(s)

Street address (including apt. no.) 7 8 Other

%

City, state, and ZIP code

Account number (see instructions) 10 State tax withheld 11 State/Payer’s state no.

$

13 Local tax withheld 14 Name of locality

$

Form 1099-R Department of the Treasury - In

1

1

$

$

$

$

$ $

$

OMB No. 1545-0119

Your percentage of total

distribution

9a

%

Form 1099-R

9b Total employee contributions

$

IRA/

SEP/

SIMPLE

2005
Box 1. Shows the total amount you received this year. The amount

may have been a direct rollover, a transfer or conversion to a Roth

IRA, a recharacterized IRA contribution; or you may have received it

as periodic payments, as nonperiodic payments, or as a total

distribution. Report the amount on Form 1040 or 1040A on the line

for “IRA distributions” or “Pensions and annuities” (or the line for

“Taxable amount”), and on Form 8606, whichever applies. However,

If a life insurance, annuity, or endowment cont

tax free to another trustee or contract issuer, an 

shown in this box and Code 6 will be shown in b

report this on your tax return.

Instructions for Recipient

Generally, distributions from pensions, annuities, profit-sharing and

retirement plans (including section 457 state and local government

plans), IRAs, insurance contracts, etc., are reported to recipients on

Form 1099-R.

IRAs. For distributions from a traditional individual retirement

arrangement (IRA), simplified employee pension (SEP), or savings

incentive match plan for employees (SIMPLE), generally the payer is

not required to compute the taxable amount. Therefore, the amounts

in boxes 1 and 2a will be the same most of the time. See the Form

1040 or 1040A instructions to determine the taxable amount. If you

are at least age 701⁄2 , you must take minimum distributions from

your IRA (other than a Roth IRA). If you do not, you may be subject

to a 50% excise tax on the amount that should have been

distributed. See Pub. 590, Individual Retirement Arrangements (IRAs),

and Pub. 560, Retirement Plans for Small Business (SEP, SIMPLE,

and Qualified Plans), for more information on IRAs.

(Continued on the 

Box 2a. This part of the distribution is generally t

no entry in this box, the payer may not have all t

figure the taxable amount. In that case, the first b

should be checked. You may want to get one of 

publications from the IRS to help you figure the t

Pub. 560, Pub. 571, Tax-Sheltered Annuity Plans 

Employees of Public Schools and Certain Tax-Ex

Pub. 575, Pub. 590, Pub. 721, Tax Guide to U.S. 

Retirement Benefits, or Pub. 939, General Rule fo

Annuities. For an IRA distribution, see IRAs and R

For a direct rollover, zero should be shown, and 

(-0-) on the “Taxable amount” line of your tax ret

If this is a total distribution from a qualified pla

or tax-sheltered annuity) and you were born befo

(or you are the beneficiary of someone born befo

you may be eligible for the 10-year tax option. Se

for Form 4972 for more information.

Box 2b. If the first box is checked, the payer was 

determine the taxable amount, and box 2a shoul

However, if this is a traditional IRA, SEP, or SIMP

then see IRAs above. If the second box is checke

was a total distribution that closed out your acco

Loans treated as distributions. If you borrow money from a

qualified plan, tax-sheltered annuity, or government plan, you may

have to treat the loan as a distribution and include all or part of the

amount borrowed in your income. There are exceptions to this rule.

If your loan is taxable, Code L will be shown in box 7. See Pub. 575.

Qualified plans. If your annuity starting date is after 1997, you must

use the simplified method to figure your taxable amount if your payer

did not show the taxable amount in box 2a. See Pub. 575, Pension

and Annuity Income.

Roth IRAs. For distributions from a Roth IRA, generally the payer is

not required to compute the taxable amount. You must compute any

taxable amount on Form 8606, Nondeductible IRAs. An amount

shown in box 2a may be taxable earnings on an excess contribution.

if this is a lump-sum distribution, report it on For

Lump-Sum Distributions. If you have not reached 

retirement age, report your disability payments o

“Wages, salaries, tips, etc.” on your tax return. A

line corrective distributions of excess deferrals, e

or excess aggregate contributions.

Box 3. If you received a lump-sum distribution fr

and were born before January 2, 1936 (or you ar

someone born before January 2, 1936), you may 

treat this amount as a capital gain on Form 4972 

(Form 1040)). See the Instructions for Form 4972

gift annuity, report as a long-term capital gain on 

Account number. May show an account or other unique number the

payer assigned to distinguish your account.
Employee contributions

or insurance premiums

CORRECTED (if checked)

PAYER’S name, street address, city, state, and ZIP code 1 Gross distribution Di

Pen

$

2a Taxable amount

$

Total

distribution

Taxable amount

not determined

2b

RECIPIENT’S identification

number

PAYER’S Federal identification

number

3 Capital gain (included

in box 2a)

4 Federal income tax

withheld

$ $

RECIPIENT’S name Net unrealized

appreciation in

employer’s securities

5 6

$ $

Distribution

code(s)

Street address (including apt. no.) 7 8 Other

%

City, state, and ZIP code

Account number (see instructions) 10 State tax withheld 11 State/Payer’s state no.

$

13 Local tax withheld 14 Name of locality

$

Form 1099-R Department of the Treasury - In

1

1

$

(keep for your records)

$

$

$ $

$ $

OMB No. 1545-0119

Your percentage of total

distribution

9a

%

Form 1099-R

9b Total employee contributions

$

IRA/

SEP/

SIMPLE

2005
If the IRA/SEP/SIMPLE box is checked, you ha

traditional IRA, SEP, or SIMPLE distribution.

Box 8. If you received an annuity contract as par

the value of the contract is shown. It is not taxab

it and should not be included in boxes 1 and 2a. 

periodic payments from the annuity contract, the

time. If the distribution is made to more than one 

percentage of the annuity contract distributed to 

You will need this information if you use the 10-y

(Form 4972).

Box 9a. If a total distribution was made to more 

the percentage you received is shown.

Boxes 10–15. If state or local income tax was wi

distribution, these boxes may be completed. Box

show the part of the distribution subject to state 

Box 4. This is the amount of federal income tax withheld. Include

this on your income tax return as tax withheld, and if box 4

shows an amount (other than zero), attach Copy B to your

return. Generally, if you will receive payments next year that are not

eligible rollover distributions, you can change your withholding or

elect not to have income tax withheld by giving the payer Form

W-4P, Withholding Certificate for Pension or Annuity Payments.

Box 5. Generally, this shows the employee’s investment in the

contract (after-tax contributions), if any, recovered tax free this year;

the part of premiums paid on commercial annuities or insurance

contracts recovered tax free; or the nontaxable part of a charitable

gift annuity. This box does not show any IRA contributions.

Box 6. If you received a lump-sum distribution from a qualified plan

that includes securities of the employer’s company, the net unrealized

appreciation (NUA) (any increase in value of such securities while in

the trust) is taxed only when you sell the securities unless you choose

to include it in your gross income this year. See Pub. 575 and the

Instructions for Form 4972. If you did not receive a lump-sum

distribution, the amount shown is the NUA attributable to employee

contributions, which is not taxed until you sell the securities.

Box 7. The following codes identify the distribution you received.

1—Early distribution, no known exception (in most cases, under age

591⁄2 ). See the Form 1040/1040A instructions and Form 5329,

Additional Taxes on Qualified Plans (Including IRAs) and Other

Tax-Favored Accounts. For a rollover of the entire distribution, do

not file Form 5329. See the Form 1040/1040A instructions for how to

report the rollover. 2—Early distribution, exception applies (under

age 591⁄2 )*. 3—Disability*. 4—Death*. 5—Prohibited transaction.

6—Section 1035 exchange (a tax-free exchange of life insurance,

annuity, or endowment contracts). 7—Normal distribution. 8—Excess

contributions plus earnings/excess deferrals (and/or earnings) taxable

in 2005. 9—Cost of current life insurance protection (premiums paid

by a trustee or custodian for current insurance protection, taxable to

you currently). A—May be eligible for 10-year tax option. See Form

4972. D—Excess contributions plus earnings/excess deferrals

taxable in 2003. E—Excess annual additions under section 415 and

certain excess amounts under section 403(b) plans. Report on Form

1040/1040A on the line for taxable pension or annuity income*.

F—Charitable gift annuity. G—Direct rollover to a qualified plan, a

Instructions for Recipient ( Continued)

Box 9b. For a life annuity from a qualified plan or 

annuity (with after-tax contributions), an amount m

employee’s total investment in the contract. It is u

taxable part of the distribution. See Pub. 575.

*You are not required to file Form 5329.

tax-sheltered annuity, a governmental 457(b) plan

also include a transfer from a conduit IRA to a qu

J—Early distribution from a Roth IRA, no known 

cases, under age 591⁄2 ). Report on Forms 1040 a

Form 5329. L—Loans treated as distributions. N—

IRA contribution made for 2005 and recharacteriz

on 2005 Form 1040/1040A and Form 8606, if ap

contributions plus earnings/excess deferrals taxa

Q—Qualified distribution from a Roth IRA. You ar

and meet the 5-year holding period for a Roth IR

1040/1040A instructions*. R—Recharacterized IR

for 2004 and recharacterized in 2005. Report on 

1040/1040A and Form 8606, if applicable. S—Ea

a SIMPLE IRA in first 2 years, no known exceptio

May be subject to an additional 25% tax. See Fo

IRA distribution, exception applies. You are age 5

disabled, or are the beneficiary of a participant w

not meet the 5-year holding period.) See the Form 

instructions.
Employee contributions

or insurance premiums

CORRECTED (if checked)

PAYER’S name, street address, city, state, and ZIP code 1 Gross distribution Di

Pen

$

2a Taxable amount

$

Total

distribution

Taxable amount

not determined

2b

RECIPIENT’S identification

number

PAYER’S Federal identification

number

3 Capital gain (included

in box 2a)

4 Federal income tax

withheld

$ $

RECIPIENT’S name Net unrealized

appreciation in

employer’s securities

5 6

$ $

Distribution

code(s)

Street address (including apt. no.) 7 8 Other

%

City, state, and ZIP code

Account number (see instructions) 10 State tax withheld 11 State/Payer’s state no.

$

13 Local tax withheld 14 Name of locality

$

Form 1099-R Department of the Treasury - In

1

1

$

$

$

$ $

$ $

OMB No. 1545-0119

Your percentage of total

distribution

9a

%

Form 1099-R

9b Total employee contributions

$

IRA/

SEP/

SIMPLE

2005
Employee contributions

or insurance premiums

VOID CORRECTED

PAYER’S name, street address, city, state, and ZIP code 1 Gross distribution Di

Pen

$

2a Taxable amount

$

Total

distribution

Taxable amount

not determined

2b

RECIPIENT’S identification

number

PAYER’S Federal identification

number

3 Capital gain (included

in box 2a)

4 Federal income tax

withheld

$ $

RECIPIENT’S name Net unrealized

appreciation in

employer’s securities

5 6

$ $

Distribution

code(s)

Street address (including apt. no.) 7 8 Other

%

City, state, and ZIP code

Account number (see instructions) 10 State tax withheld 11 State/Payer’s state no.

$

13 Local tax withheld 14 Name of locality

$

Form 1099-R Department of the Treasury - In

1

1

$

$

$

$ $

$ $

OMB No. 1545-0119

Your percentage of total

distribution

9a

%

Form 1099-R

9b Total employee contributions

$

IRA/

SEP/

SIMPLE

2005
Instructions for Payers

Due dates. Furnish Copies B an

form to the recipient by January 

File Copy A of this form with th

February 28, 2006. If you file elec

the due date is March 31, 2006.

Printed on recycled paper

Caution: Because paper forms a

during processing, you cannot fil

IRS Forms 1096, 1098, 1099, or 

you print from the IRS website.

We provide general and specific form

instructions as separate products. The

products you should use for 2005 are the

General Instructions for Forms 1099, 1098,

5498, and W-2G and the 2005 Instructions for

Forms 1099-R and 5498. A chart in the

general instructions gives a quick guide to

which form must be filed to report a particular

payment. To order these instructions and

additional forms, call 1-800-TAX-FORM

(1-800-829-3676).