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 Distributions From

Pensions, Annuities,

Retirement or

Profit-Sharing

Plans, IRAs,

Insurance

Contracts, etc.

$

2a Taxable amount

$

Total

distribution

Taxable amount

not determined

2b Copy A

RECIPIENT’S identification

number

PAYER’S Federal identification

number

3 Capital gain (included

in box 2a)

4 Federal income tax

withheld

For

Internal Revenue

Service Center

$ $

RECIPIENT’S name Net unrealized

appreciation in

employer’s securities

5 6 For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2004 General

Instructions for

Forms 1099,

1098, 5498,

and W-2G.

$ $

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 (optional) 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 - Internal Revenue Service

File with Form 1096.

Cat. No. 14436Q

12

15

State distribution

Local distribution

$

$

$

$

$ $

$

Form 1099-R

9b Total employee contributions

$

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

2004
Employee contributions

or insurance premiums

VOID CORRECTED

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

Pensions, Annuities,

Retirement or

Profit-Sharing

Plans, IRAs,

Insurance

Contracts, etc.

$

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 (optional) 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 - Internal Revenue Service

12

15

State distribution

Local distribution

$

Copy 1

For

State, City,

or Local

Tax Department

$

$

$

$

$

$

OMB No. 1545-0119

Your percentage of total

distribution

9a

%

Form 1099-R

9b Total employee contributions

$

IRA/

SEP/

SIMPLE

2004
Employee contributions

or insurance premiums

CORRECTED (if checked)

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

Pensions, Annuities,

Retirement or

Profit-Sharing

Plans, IRAs,

Insurance

Contracts, etc.

$

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 (optional) 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 - Internal Revenue Service

12

15

State distribution

Local distribution

$

Copy B

Report this

income on your

Federal tax

return. If this

form shows

Federal income

tax withheld in

box 4, attach

this copy to

your return.

This information is

being furnished to

the Internal

Revenue Service.

$

$

$

$ $

$

OMB No. 1545-0119

Your percentage of total

distribution

9a

%

Form 1099-R

9b Total employee contributions

$

IRA/

SEP/

SIMPLE

2004
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 this is a lump-sum distribution, report it on Form 4972, Tax on

If a life insurance, annuity, or endowment contract was transferred

tax free to another trustee or contract issuer, an amount will be

shown in this box and Code 6 will be shown in box 7. You need not

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 back of Copy C.)

Box 2a. This part of the distribution is generally taxable. If there is

no entry in this box, the payer may not have all the facts needed to

figure the taxable amount. In that case, the first box in box 2b

should be checked. You may want to get one of the following

publications from the IRS to help you figure the taxable amount:

Pub. 560, Pub. 571, Tax-Sheltered Annuity Plans (403(b) Plans) for

Employees of Public Schools and Certain Tax-Exempt Organizations,

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

Retirement Benefits, or Pub. 939, General Rule for Pensions and

Annuities. For an IRA distribution, see IRAs and Roth IRAs above.

For a direct rollover, zero should be shown, and you must enter zero

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

If this is a total distribution from a qualified plan (other than an IRA

or tax-sheltered annuity) and you were born before January 2, 1936

(or you are the beneficiary of someone born before January 2, 1936),

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

for Form 4972 for more information.

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

determine the taxable amount, and box 2a should be blank.

However, if this is a traditional IRA, SEP, or SIMPLE distribution,

then see IRAs above. If the second box is checked, the distribution

was a total distribution that closed out your account.

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.

Lump-Sum Distributions. If you have not reached minimum

retirement age, report your disability payments on the line for

“Wages, salaries, tips, etc.” Also report on that line corrective

distributions of excess deferrals, excess contributions, or excess

aggregate contributions.

Box 3. If you received a lump-sum distribution from a qualified plan

and were born before January 2, 1936 (or you are the beneficiary of

someone born before January 2, 1936), you may be able to elect to

treat this amount as a capital gain on Form 4972 (not on Schedule D

(Form 1040)). See the Instructions for Form 4972. For a charitable

gift annuity, report as a long-term capital gain on Schedule D (Form

1040).
Employee contributions

or insurance premiums

CORRECTED (if checked)

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

Pensions, Annuities,

Retirement or

Profit-Sharing

Plans, IRAs,

Insurance

Contracts, etc.

$

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 (optional) 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 - Internal Revenue Service

12

15

State distribution

Local distribution

$

This information is

being furnished to

the Internal

Revenue Service.

Copy C

For Recipient’s

Records

(keep for your records)

$

$

$ $

$ $

OMB No. 1545-0119

Your percentage of total

distribution

9a

%

Form 1099-R

9b Total employee contributions

$

IRA/

SEP/

SIMPLE

2004
If the IRA/SEP/SIMPLE box is checked, you have received a

traditional IRA, SEP, or SIMPLE distribution.

Box 8. If you received an annuity contract as part of a distribution,

the value of the contract is shown. It is not taxable when you receive

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

periodic payments from the annuity contract, they are taxable at that

time. If the distribution is made to more than one person, the

percentage of the annuity contract distributed to you is also shown.

You will need this information if you use the 10-year tax option

(Form 4972).

Box 9a. If a total distribution was made to more than one person,

the percentage you received is shown.

Boxes 10–15. If state or local income tax was withheld from the

distribution, these boxes may be completed. Boxes 12 and 15 may

show the part of the distribution subject to state and/or local tax.

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 to a traditional IRA of the entire

taxable part of the distribution, do not file Form 5329. See the Form

1040/1040A instructions. 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 2004. 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

2002. 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*.

Instructions for Recipient ( Continued)

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

annuity (with after-tax contributions), an amount may be shown for the

employee’s total investment in the contract. It is used to compute the

taxable part of the distribution. See Pub. 575.

*You are not required to file Form 5329.

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

tax-sheltered annuity, a governmental 457(b) plan, or an IRA. May

also include a transfer from a conduit IRA to a qualified plan*.

J—Early distribution from a Roth IRA, no known exception (in most

cases, under age 591⁄2 ). Report on Forms 1040 and 8606 and see

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

IRA contribution made for 2004 and recharacterized in 2004. Report

on 2004 Form 1040/1040A and Form 8606, if applicable. P—Excess

contributions plus earnings/excess deferrals taxable in 2003.

Q—Qualified distribution from a Roth IRA. You are age 591⁄2 or over

and meet the 5-year holding period for a Roth IRA. See the Form

1040/1040A instructions*. R—Recharacterized IRA contribution made

for 2003 and recharacterized in 2004. Report on 2003 Form

1040/1040A and Form 8606, if applicable. S—Early distribution from

a SIMPLE IRA in first 2 years, no known exception (under age 591⁄2 ).

May be subject to an additional 25% tax. See Form 5329. T—Roth

IRA distribution, exception applies. (You may not meet the 5-year

holding period.) You are either age 591⁄2 or over or an exception

(code 3 or 4) applies. See the Form 1040/1040A instructions.
Employee contributions

or insurance premiums

CORRECTED (if checked)

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

Pensions, Annuities,

Retirement or

Profit-Sharing

Plans, IRAs,

Insurance

Contracts, etc.

$

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 (optional) 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 - Internal Revenue Service

12

15

State distribution

Local distribution

$

Copy 2

File this copy

with your state,

city, or local

income tax

return, when

required.

$

$

$ $

$ $

OMB No. 1545-0119

Your percentage of total

distribution

9a

%

Form 1099-R

9b Total employee contributions

$

IRA/

SEP/

SIMPLE

2004
Employee contributions

or insurance premiums

VOID CORRECTED

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

Pensions, Annuities,

Retirement or

Profit-Sharing

Plans, IRAs,

Insurance

Contracts, etc.

$

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 (optional) 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 - Internal Revenue Service

12

15

State distribution

Local distribution

$

Copy D

For Payer

$

$

$ $

$ $

OMB No. 1545-0119

Your percentage of total

distribution

9a

%

Form 1099-R

9b Total employee contributions

$

IRA/

SEP/

SIMPLE

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2004 General

Instructions for

Forms 1099,

1098, 5498,

and W-2G.

2004
Instructions for Payers

Due dates. Furnish Copies B and C of this

form to the recipient by January 31, 2005.

File Copy A of this form with the IRS by

February 28, 2005. If you file electronically,

the due date is March 31, 2005.

Caution: Because paper forms are scanned

during processing, you cannot file with the

IRS Forms 1096, 1098, 1099, or 5498 that

you print from the IRS website.

We now provide general and specific form

instructions as separate products. The

products you should use for 2004 are the

General Instructions for Forms 1099, 1098,

5498, and W-2G and the 2004 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).