Form 1099-R

2015

Cat. No. 14436Q

Distributions From 

Pensions, Annuities, 

Retirement or 

Profit-Sharing 

 Plans, IRAs, 

Insurance 

Contracts, etc.

Copy A 

For 

Internal Revenue 

Service Center 

File with Form 1096.

Department of the Treasury - Internal Revenue Service

OMB No. 1545-0119

For Privacy Act 

and Paperwork 

Reduction Act 

Notice, see the 

2015 General 

Instructions for 

Certain 

Information 

Returns.

9898 VOID CORRECTED

PAYER’S name, street address, city or town, state or province, 

country, and ZIP or foreign postal code

PAYER’S federal identification 

number

RECIPIENT’S identification 

number

RECIPIENT’S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal 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

$

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 www.irs.gov/form1099r

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

Form 1099-R

2015

Distributions From 

Pensions, Annuities, 

Retirement or 

Profit-Sharing 

 Plans, IRAs, 

Insurance 

Contracts, etc.

Copy 1 

For 

State, City, 

or Local 

Tax Department

Department of the Treasury - Internal Revenue Service

OMB No. 1545-0119

VOID CORRECTED

PAYER’S name, street address, city or town, state or province, 

country, and ZIP or foreign postal code

PAYER’S federal identification 

number

RECIPIENT’S identification 

number

RECIPIENT’S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal 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

$

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 www.irs.gov/form1099r
 

Form 1099-R

2015

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. 

Department of the Treasury - Internal Revenue Service

This information is 

being furnished to 

the Internal 

Revenue Service.

OMB No. 1545-0119

CORRECTED (if checked)

PAYER’S name, street address, city or town, state or province, 

country, and ZIP or foreign postal code

PAYER’S federal identification 

number

RECIPIENT’S identification 

number

RECIPIENT’S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal 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

$

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 www.irs.gov/form1099r
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.

Recipient's identification number. For your protection, this form 

may show only the last four digits of your social security number 

(SSN), individual taxpayer identification number (ITIN), adoption 

taxpayer identification number (ATIN), or employer identification 

number (EIN). However, the issuer has reported your complete 

identification number to the IRS.

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.)
 

Form 1099-R

2015

Distributions From 

Pensions, Annuities, 

Retirement or 

Profit-Sharing 

 Plans, IRAs, 

Insurance 

Contracts, etc.

Copy C 

For Recipient's 

Records

Department of the Treasury - Internal Revenue Service

This information is 

being furnished to 

the Internal 

Revenue Service.

OMB No. 1545-0119

CORRECTED (if checked)

PAYER’S name, street address, city or town, state or province, 

country, and ZIP or foreign postal code

PAYER’S federal identification 

number

RECIPIENT’S identification 

number

RECIPIENT’S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal 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

$

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) www.irs.gov/form1099r
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 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. It 

is your responsibility to determine the taxable amount. 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 as explained in the 

instructions for Form 8949.

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 Form 5329.

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 2015.

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 Form 5329.

D—Annuity payments from nonqualified annuities that may be subject 

to tax under section 1411.

(Continued on the back of Copy 2.)
 

Form 1099-R

2015

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. 

Department of the Treasury - Internal Revenue Service

OMB No. 1545-0119

CORRECTED (if checked)

PAYER’S name, street address, city or town, state or province, 

country, and ZIP or foreign postal code

PAYER’S federal identification 

number

RECIPIENT’S identification 

number

RECIPIENT’S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal 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

$

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 www.irs.gov/form1099r
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).

K—Distribution of IRA assets not having a readily available FMV.

L—Loans treated as distributions.

N—Recharacterized IRA contribution made for 2015 and

recharacterized in 2015.

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

earnings) taxable in 2014.

Q—Qualified distribution from a Roth IRA.

R—Recharacterized IRA contribution made for 2014 and

recharacterized in 2015.

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 

Form 5329 and Pub. 575.

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.

Future developments. For the latest information about developments 

related to Form 1099-R and its instructions, such as legislation 

enacted after they were published, go to www.irs.gov/form1099r.

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.
 

Form 1099-R

2015

Distributions From 

Pensions, Annuities, 

Retirement or 

Profit-Sharing 

 Plans, IRAs, 

Insurance 

Contracts, etc.

Copy D 

For Payer 

Department of the Treasury - Internal Revenue Service

OMB No. 1545-0119

For Privacy Act 

and Paperwork 

Reduction Act 

Notice, see the 

2015 General

Instructions for

Certain 

Information 

Returns.

VOID CORRECTED

PAYER’S name, street address, city or town, state or province, 

country, and ZIP or foreign postal code

PAYER’S federal identification 

number

RECIPIENT’S identification 

number

RECIPIENT’S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal 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

$

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 www.irs.gov/form1099r
Instructions for Payer

To complete Form 1099-R, use: 

• the 2015 General Instructions for Certain 

Information Returns, and

• the 2015 Instructions for Forms 1099-R and 

5498.

To order these instructions and additional 

forms, go to www.irs.gov/form1099r or call 

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

Caution. Because paper forms are scanned

during processing, you cannot file 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 February 1, 2016.

File Copy A of this form with the IRS by 

February 29, 2016. If you file electronically, the 

due date is March 31, 2016. To file 

electronically, you must have software that 

generates a file according to the specifications 

in Pub. 1220, Specifications for Electronic 

Filing of Forms 1097, 1098, 1099, 3921, 3922, 

5498, and W-2G. The 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). Persons with a hearing or speech 

disability with access to TTY/TDD equipment 

can call 304-579-4827 (not toll free).