9898 VOID CORRECTED

PAYER’S name, street address, city, state, and ZIP code

PAYER’S federal identification 

number

RECIPIENT’S identification 

number

RECIPIENT’S name

Street address (including apt. no.)

City, state, and ZIP code

10 Amount allocable to IRR 

within 5 years

$

11 1st year of desig. Roth contrib.

Account number (see instructions)

1 Gross distribution

$

2a Taxable amount

$

OMB No. 1545-0119

2011

Form 1099-R

Distributions From 

Pensions, Annuities, 

Retirement or 

Profit-Sharing 

 Plans, IRAs, 

Insurance 

Contracts, etc.

Copy A 

For 

Internal Revenue 

Service Center 

File with Form 1096.

For Privacy Act 

and Paperwork 

Reduction Act 

Notice, see the 

2011 General 

Instructions for 

Certain 

Information 

Returns.

2b Taxable amount

not determined

Total 

distribution

3 Capital gain (included

in box 2a)

$

4 Federal income tax

withheld

$

5 Employee contributions

/Designated Roth

contributions or 

insurance premiums

$

6 Net unrealized

appreciation in

employer’s securities

$

7 Distribution 

 code(s)

IRA/ 

SEP/ 

SIMPLE

8 Other

$ %

9a Your percentage of total

distribution %

9b Total employee contributions

$

12 State tax withheld

$

$

13 State/Payer’s state no. 14 State distribution

$

$

15 Local tax withheld

$

$

16 Name of locality 17 Local distribution

$

$

Form 1099-R Cat. No. 14436Q Department of the Treasury - Internal Revenue Service

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

PAYER’S name, street address, city, state, and ZIP code

PAYER’S federal identification 

number

RECIPIENT’S identification 

number

RECIPIENT’S name

Street address (including apt. no.)

City, state, and ZIP code

10 Amount allocable to IRR 

within 5 years

$

11 1st year of desig. Roth contrib.

Account number (see instructions)

1 Gross distribution

$

2a Taxable amount

$

OMB No. 1545-0119

2011

Form 1099-R

Distributions From 

Pensions, Annuities, 

Retirement or 

Profit-Sharing 

 Plans, IRAs, 

Insurance 

Contracts, etc.

Copy 1 

For 

State, City, 

or Local 

Tax Department

2b Taxable amount

not determined

Total 

distribution

3 Capital gain (included

in box 2a)

$

4 Federal income tax

withheld

$

5 Employee contributions

/Designated Roth

contributions or 

insurance premiums

$

6 Net unrealized

appreciation in

employer’s securities

$

7 Distribution 

 code(s)

IRA/ 

SEP/ 

SIMPLE

8 Other

$ %

9a Your percentage of total

distribution %

9b Total employee contributions

$

12 State tax withheld

$

$

13 State/Payer’s state no. 14 State distribution

$

$

15 Local tax withheld

$

$

16 Name of locality 17 Local distribution

$

$

Form 1099-R Department of the Treasury - Internal Revenue Service
CORRECTED (if checked)

PAYER’S name, street address, city, state, and ZIP code

PAYER’S federal identification 

number

RECIPIENT’S identification 

number

RECIPIENT’S name

Street address (including apt. no.)

City, state, and ZIP code

10 Amount allocable to IRR 

within 5 years

$

11 1st year of desig. Roth contrib.

Account number (see instructions)

1 Gross distribution

$

2a Taxable amount

$

OMB No. 1545-0119

2011

Form 1099-R

Distributions From 

Pensions, Annuities, 

Retirement or 

Profit-Sharing 

 Plans, IRAs, 

Insurance 

Contracts, etc.

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.

2b Taxable amount

not determined

Total 

distribution

3 Capital gain (included

in box 2a)

$

4 Federal income tax

withheld

$

5 Employee contributions

/Designated Roth

contributions or 

insurance premiums

$

6 Net unrealized

appreciation in

employer’s securities

$

7 Distribution 

 code(s)

IRA/ 

SEP/ 

SIMPLE

8 Other

$ %

9a Your percentage of total

distribution %

9b Total employee contributions

$

12 State tax withheld

$

$

13 State/Payer’s state no. 14 State distribution

$

$

15 Local tax withheld

$

$

16 Name of locality 17 Local distribution

$

$

Form 1099-R Department of the Treasury - Internal Revenue Service
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.

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 the 

instructions for Form 1040 or 1040A.

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. 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 for more information on IRAs.

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. An amount shown in 

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

Loans treated as distributions. If you borrow money from a

qualified plan, section 403(b) plan, or governmental section 457(b) 

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.

Account number. May show an account or other unique number 

the payer assigned to distinguish your account.

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,

as applicable. However, if this is a lump-sum distribution, see

Form 4972. If you have not reached minimum retirement age,

report your disability payments on the line for “Wages, salaries,

tips, etc.” on your tax return. Also report on that line permissible

withdrawals from eligible automatic contribution arrangements

and corrective distributions of excess deferrals, excess

contributions, or excess aggregate contributions except if you are 

self-employed.

 If a life insurance, annuity, qualified long-term care, 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. If a charge or payment was made against 

the cash value of an annuity contract or the cash surrender value 

of a life insurance contract for the purchase of qualified long-term 

care insurance, an amount will be shown in this box and Code W 

will be shown in box 7. You need not report these amounts on 

your tax return.

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 free

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

See Additional information on the back of Copy 2. For an IRA

distribution, see IRAs and Roth IRAs on this page. For a direct 

rollover, other than from a qualified plan to a Roth IRA, zero 

should be shown, and you must enter zero (-0-) on the “Taxable 

amount” line of your tax return. 

(Continued on the back of Copy C.)
CORRECTED (if checked)

PAYER’S name, street address, city, state, and ZIP code

PAYER’S federal identification 

number

RECIPIENT’S identification 

number

RECIPIENT’S name

Street address (including apt. no.)

City, state, and ZIP code

10 Amount allocable to IRR 

within 5 years

$

11 1st year of desig. Roth contrib.

Account number (see instructions)

1 Gross distribution

$

2a Taxable amount

$

OMB No. 1545-0119

2011

Form 1099-R

Distributions From 

Pensions, Annuities, 

Retirement or 

Profit-Sharing 

 Plans, IRAs, 

Insurance 

Contracts, etc.

Copy C 

For Recipient's 

Records

This information is 

being furnished to 

the Internal 

Revenue Service.

2b Taxable amount

not determined

Total 

distribution

3 Capital gain (included

in box 2a)

$

4 Federal income tax

withheld

$

5 Employee contributions

/Designated Roth

contributions or 

insurance premiums

$

6 Net unrealized

appreciation in

employer’s securities

$

7 Distribution 

 code(s)

IRA/ 

SEP/ 

SIMPLE

8 Other

$ %

9a Your percentage of total

distribution %

9b Total employee contributions

$

12 State tax withheld

$

$

13 State/Payer’s state no. 14 State distribution

$

$

15 Local tax withheld

$

$

16 Name of locality 17 Local distribution

$

$

Form 1099-R (keep for your records) Department of the Treasury - Internal Revenue Service
Instructions for Recipient (Continued)

 If this is a total distribution from a qualified plan 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 Form 4972 instructions for more information.

If you are an eligible retired public safety officer who elected to 

exclude from income distributions from your eligible plan used to pay 

certain insurance premiums, the amount shown in box 2a has not 

been reduced by the exclusion amount. See the instructions for Form 

1040 or Form 1040A 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, except for an IRA. If 

the second box is checked, the distribution was a total distribution 

that closed out your account. 

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 Form 4972 instructions. For a charitable gift

annuity, report as a long-term capital gain on Schedule D.

Box 4. Shows federal income tax withheld. Include this amount 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.

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

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

the portion that is your basis in a designated Roth account; 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. If the amount shown is 

your basis in a designated Roth account, the year you first made

contributions to that account may be entered in box 11.

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

Form 4972 instructions. 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. For

more information on these distributions, see the instructions for your

tax return. Also, certain distributions may be subject to an additional

10% tax. See the instructions for Forms 5329 and 8606.

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

591⁄2).

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, qualified long-term care insurance, or endowment 

contracts).

7—Normal distribution.

8—Excess contributions plus earnings/excess deferrals (and/or

earnings) taxable in 2011.

9—Cost of current life insurance protection.

A—May be eligible for 10-year tax option (see Form 4972).

B—Designated Roth account distribution.

Note. If Code B is in box 7 and an amount is reported in box 10, 

see the instructions for Forms 5329 and 8606.

(Continued on the back of Copy 2.)
CORRECTED (if checked)

PAYER’S name, street address, city, state, and ZIP code

PAYER’S federal identification 

number

RECIPIENT’S identification 

number

RECIPIENT’S name

Street address (including apt. no.)

City, state, and ZIP code

10 Amount allocable to IRR 

within 5 years

$

11 1st year of desig. Roth contrib.

Account number (see instructions)

1 Gross distribution

$

2a Taxable amount

$

OMB No. 1545-0119

2011

Form 1099-R

Distributions From 

Pensions, Annuities, 

Retirement or 

Profit-Sharing 

 Plans, IRAs, 

Insurance 

Contracts, etc.

Copy 2 

File this copy 

with your state, 

city, or local 

income tax 

return, when 

required. 

2b Taxable amount

not determined

Total 

distribution

3 Capital gain (included

in box 2a)

$

4 Federal income tax

withheld

$

5 Employee contributions

/Designated Roth

contributions or 

insurance premiums

$

6 Net unrealized

appreciation in

employer’s securities

$

7 Distribution 

 code(s)

IRA/ 

SEP/ 

SIMPLE

8 Other

$ %

9a Your percentage of total

distribution %

9b Total employee contributions

$

12 State tax withheld

$

$

13 State/Payer’s state no. 14 State distribution

$

$

15 Local tax withheld

$

$

16 Name of locality 17 Local distribution

$

$

Form 1099-R Department of the Treasury - Internal Revenue Service
Instructions for Recipient (Continued)

E—Distributions under Employee Plans Compliance Resolution 

System (EPCRS).

F—Charitable gift annuity.

G—Direct rollover of a distribution (other than a designated Roth

account distribution) to a qualified plan, a section 403(b) plan, 

a governmental section 457(b) plan, or an IRA.

H—Direct rollover of a designated Roth account distribution to a

Roth IRA.

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

most cases, under age 591⁄2).

L—Loans treated as distributions.

N—Recharacterized IRA contribution made for 2011 and

recharacterized in 2011.

P—Excess contributions plus earnings/excess deferrals (and/or 

earnings) taxable in 2010.

Q—Qualified distribution from a Roth IRA.

R—Recharacterized IRA contribution made for 2010 and

recharacterized in 2011.

S—Early distribution from a SIMPLE IRA in first 2 years, no known 

exception (under age 591⁄2).

T—Roth IRA distribution, exception applies.

U—Dividend distribution from ESOP under sec. 404(k).

Note. This distribution is not eligible for rollover.

W—Charges or payments for purchasing qualified long-term care 

insurance contracts under combined arrangements.

 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). If charges were made 

for qualified long-term care insurance contracts under combined 

arrangements, the amount of the reduction in the investment (but 

not below zero) in the annuity or life insurance contract is reported 

here. 

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

the percentage you received is shown.

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

403(b) plan (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.

Box 10. If an amount is reported in this box, see the instructions 

for Forms 5329 and 8606.

Box 11. The 1st year you made a contribution to the designated 

Roth account reported on this form is shown in this box.

Boxes 12—17. If state or local income tax was withheld from the

distribution, boxes 14 and 17 may show the part of the

distribution subject to state and/or local tax.

Additional information. You may want to see:

Form W-4P, Withholding Certificate for Pension or Annuity

Payments,

Form 4972, Tax on Lump-Sum Distributions,

Form 5329, Additional Taxes on Qualified Plans (Including IRAs)

and Other Tax-Favored Accounts,

Form 8606, Nondeductible IRAs,

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

and Qualified Plans),

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

Pub. 575, Pension and Annuity Income,

Pub. 590, Individual Retirement Arrangements (IRAs),

Pub. 721, Tax Guide to U.S. Civil Service Retirement Benefits,

Pub. 939, General Rule for Pensions and Annuities,

Pub. 969, Health Savings Accounts and Other Tax-Favored

Health Plans.
VOID CORRECTED

PAYER’S name, street address, city, state, and ZIP code

PAYER’S federal identification 

number

RECIPIENT’S identification 

number

RECIPIENT’S name

Street address (including apt. no.)

City, state, and ZIP code

10 Amount allocable to IRR 

within 5 years

$

11 1st year of desig. Roth contrib.

Account number (see instructions)

1 Gross distribution

$

2a Taxable amount

$

OMB No. 1545-0119

2011

Form 1099-R

Distributions From 

Pensions, Annuities, 

Retirement or 

Profit-Sharing 

 Plans, IRAs, 

Insurance 

Contracts, etc.

Copy D 

For Payer 

For Privacy Act 

and Paperwork 

Reduction Act 

Notice, see the 

2011 General

Instructions for

Certain 

Information 

Returns.

2b Taxable amount

not determined

Total 

distribution

3 Capital gain (included

in box 2a)

$

4 Federal income tax

withheld

$

5 Employee contributions

/Designated Roth

contributions or 

insurance premiums

$

6 Net unrealized

appreciation in

employer’s securities

$

7 Distribution 

 code(s)

IRA/ 

SEP/ 

SIMPLE

8 Other

$ %

9a Your percentage of total

distribution %

9b Total employee contributions

$

12 State tax withheld

$

$

13 State/Payer’s state no. 14 State distribution

$

$

15 Local tax withheld

$

$

16 Name of locality 17 Local distribution

$

$

Form 1099-R Department of the Treasury - Internal Revenue Service
Instructions for Payer

We provide general and specific form 

instructions as separate products. The 

products you should use to complete Form 

1099-R are the 2011 General Instructions for 

Certain Information Returns and the 2011 

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, visit IRS.gov or call 

1-800-TAX-FORM (1-800-829-3676).

Caution: Because paper forms are scanned

during processing, you cannot file with the IRS 

Forms 1096, 1097, 1098, 1099, 3921, 3922, or

5498 that you print from the IRS website.

Due dates. Furnish Copies B, C, and 2 of this 

form to the recipient by January 31, 2012.

 File Copy A of this form with the IRS by 

February 28, 2012. If you file electronically, the 

due date is April 2, 2012. To file electronically, 

you must have software that generates a file 

according to the specifications in Pub. 1220, 

Specifications for Filing Forms 1097, 1098, 

1099, 3921, 3922, 5498, 8935, and W-2G 

Electronically. IRS does not provide a fill-in 

form option.

Need help? If you have questions about

reporting on Form 1099-R, call the information 

reporting customer service site toll free at 

1-866-455-7438 or 304-263-8700 (not toll 

free). For TTY/TDD equipment, call

304-579-4827 (not toll free). The hours of 

operation are Monday through Friday from 

8:30 a.m. to 4:30 p.m., Eastern time.