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

2002 General

Instructions for

Forms 1099,

1098, 5498,

and W-2G.

$ $

IRA/

SEP/

SIMPLE

Distribution

code

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

2002
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

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

2002
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

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

2002
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. Unless this amount is from a Coverdell ESA, report it on

Form 1040 or 1040A on the line for “IRA distributions” or “Pensions

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 annunity) and you were born before 1936 (or you are

the beneficiary of someone born before 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 checkbox 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 checkbox 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.

and annunities” (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 Lump-Sum Distribution. 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 1936 (or you are the beneficiary of someone

born before 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).

Coverdell eduation savings accounts (ESAs). For distributions

from a Coverdell ESA, you must compute any taxable amount. See

your tax return instructions for reporting information.
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

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

2002
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 special 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 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 2002. 9—PS

58 costs (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 2000. 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 IRA*. H—Direct rollover to qualified plan or

tax-sheltered annuity or a transfer from a conduit IRA to a qualified

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.

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. M—Distribution

from a Coverdell ESA. Report any taxable amount on Form 1040. If

your education expenses during 2002 were not equal to or more

than your distribution, part or all of your distribution may be taxable

and subject to an additional 10% tax. N—Recharacterized IRA

contribution made for 2002 and recharacterized in 2002. Report on

2002 Form 1040/1040A and Form 8606, if applicable. P—Excess

contributions plus earnings/excess deferrals taxable in 2001. R—

Recharacterized IRA contribution made for 2001 and recharacterized

in 2002. Report on 2001 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. Report on Forms 1040/1040A and 8606. You are

either age 591⁄2 or over or an exception (code 2, 3, or 4) applies.

*You are not required to file Form 5329.
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

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

2002
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

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

2002 General

Instructions for

Forms 1099,

1098, 5498,

and W-2G.

2002
Instructions for Payers

Due dates. Furnish Copies B and C of this

form to the recipient by January 31, 2003.

File Copy A of this form with the IRS by

February 28, 2003. If you file electronically,

the due date is March 31, 2003.

Caution: Because the IRS processes paper

forms by machine (optical character

recognition equipment), you cannot file with

the IRS Forms 1096, 1098, 1099, or 5498

that you print from the IRS Web Site.

We now provide general and specific form

instructions as separate products. The

products you should use for 2002 are the

General Instructions for Forms 1099, 1098,

5498, and W-2G and the separate specific

instructions for each information return you

file. Specific information needed to complete

this form is given in the 2002 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).
Note: Self Duplicating, Carbon Paper Not Required