Attention: 

Copy A of this form is provided for informational purposes only. Copy A appears in red, 

similar to the official IRS form. The official printed version of Copy A of this IRS form is 

scannable, but the online version of it, printed from this website, is not. Do not print and file 

copy A downloaded from this website; a penalty may be imposed for filing with the IRS 

information return forms that can’t be scanned. See part O in the current General 

Instructions for Certain Information Returns, available at www.irs.gov/form1099, for more 

information about penalties.

Please note that Copy B and other copies of this form, which appear in black, may be 

downloaded and printed and used to satisfy the requirement to provide the information to 

the recipient.

To order official IRS information returns, which include a scannable Copy A for filing with 

the IRS and all other applicable copies of the form, visit www.IRS.gov/orderforms. Click on 

Employer and Information Returns, and we’ll mail you the forms you request and their 

instructions, as well as any publications you may order.

Information returns may also be filed electronically using the IRS Filing Information Returns 

Electronically (FIRE) system (visit www.IRS.gov/FIRE) or the IRS Affordable Care Act 

Information Returns (AIR) program (visit www.IRS.gov/AIR).

See IRS Publications 1141, 1167, and 1179 for more information about printing these tax 

forms.
 

Form 1099-R

2021

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 

2021 General 

Instructions for 

Certain 

Information 

Returns.

9898 VOID CORRECTED

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

country, ZIP or foreign postal code, and telephone no.

PAYER’S TIN RECIPIENT’S TIN

RECIPIENT’S name

Street address (including apt. no.)

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

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

$

10 Amount allocable to IRR 

within 5 years

$

11 1st year of desig. 

Roth contrib.

12 FATCA filing 

requirement

13 Date of 

payment 

14 State tax withheld

$

$

15 State/Payer’s state no. 16 State distribution

$

$

17 Local tax withheld

$

$

18 Name of locality 19 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

2021

Distributions From 

Pensions, Annuities,

Retirement or 

Profit-Sharing Plans, 

IRAs, Insurance 

Contracts, etc.

Department of the Treasury - Internal Revenue Service

Copy 1 

For 

State, City, 

or Local 

Tax Department

OMB No. 1545-0119

VOID CORRECTED

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

country, ZIP or foreign postal code, and telephone no.

PAYER’S TIN RECIPIENT’S TIN

RECIPIENT’S name

Street address (including apt. no.)

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

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

$

10 Amount allocable to IRR 

within 5 years

$

11 1st year of desig. 

Roth contrib.

12 FATCA filing 

requirement

13 Date of 

payment 

14 State tax withheld

$

$

15 State/Payer’s state no. 16 State distribution

$

$

17 Local tax withheld

$

$

18 Name of locality 19 Local distribution

$

$

Form 1099-R www.irs.gov/Form1099R
 

Form 1099-R

2021

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 IRS.

OMB No. 1545-0119

CORRECTED (if checked)

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

country, ZIP or foreign postal code, and telephone no.

PAYER’S TIN RECIPIENT’S TIN

RECIPIENT’S name

Street address (including apt. no.)

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

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

$

10 Amount allocable to IRR 

within 5 years

$

11 1st year of desig. 

Roth contrib.

12 FATCA filing 

requirement

13 Date of 

payment 

14 State tax withheld

$

$

15 State/Payer’s state no. 16 State distribution

$

$

17 Local tax withheld

$

$

18 Name of locality 19 Local distribution

$

$

Form 1099-R www.irs.gov/Form1099R
Instructions for Recipient

Generally, distributions from retirement plans (IRAs, qualified plans,

section 403(b) plans, and governmental section 457(b) plans), 

insurance contracts, etc., are reported to recipients on Form 1099-R.

Qualified plans and section 403(b) plans. If your annuity starting 

date is after 1997, you must use the simplified method to figure your 

taxable amount if your payer didn’t show the taxable amount in box 

2a. See the instructions for your tax return.

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 isn’t 

required to compute the taxable amount. See the instructions for your 

tax return to determine the taxable amount. If you’re at least age 72, 

you must take minimum distributions from your IRA (other than a Roth 

IRA). If you don’t, you’re subject to a 50% excise tax on the amount 

that should’ve been distributed. See Pub. 590-A and Pub. 590-B for 

more information on IRAs.

Roth IRAs. For distributions from a Roth IRA, generally the payer isn’t 

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 taxpayer identification number (TIN). For your 

protection, this form may show only the last four digits of your TIN 

(SSN, ITIN, ATIN, or EIN). However, the payer has reported your 

complete TIN to the IRS.

Account number. May show an account, policy, or other unique

number the payer assigned to distinguish your account.

Box 1. Shows the total amount distributed 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, nonperiodic payments, or a total distribution. 

Report the amount on Form 1040, 1040-SR, or 1040-NR 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 haven’t 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 the 

distribution is of designated Roth contributions or your after-tax 

contributions or if you’re 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. If code C is 

shown in box 7, the amount shown in box 1 is a receipt of reportable 

death benefits that is taxable in part.

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, earlier. 

For a direct rollover, other than from a qualified plan, section 403(b) 

plan, or governmental section 457(b) plan to a designated Roth account 

in the same plan or to a Roth IRA, zero should be shown and you must 

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

roll over a distribution (other than a distribution from a designated Roth 

account) from a qualified plan, section 403(b) plan, or governmental 

section 457(b) plan to a designated Roth account in the same plan or to 

(Continued on the back of Copy C)
 

Form 1099-R

2021

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 IRS.

OMB No. 1545-0119

CORRECTED (if checked)

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

country, ZIP or foreign postal code, and telephone no.

PAYER’S TIN RECIPIENT’S TIN

RECIPIENT’S name

Street address (including apt. no.)

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

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

$

10 Amount allocable to IRR 

within 5 years

$

11 1st year of desig. 

Roth contrib.

12 FATCA filing 

requirement

13 Date of 

payment 

14 State tax withheld

$

$

15 State/Payer’s state no. 16 State distribution

$

$

17 Local tax withheld

$

$

18 Name of locality 19 Local distribution

$

$

Form 1099-R (keep for your records) www.irs.gov/Form1099R
Instructions for Recipient (continued)

a Roth IRA, you must include on the “Taxable amount” line of your tax 

return the amount shown in this box plus the amount in box 6, if any. 

If this is a total distribution from a qualified plan and you were born 

before January 2, 1936 (or you’re 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’re 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 hasn’t been 

reduced by the exclusion amount. See the instructions for your tax 

return 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’s 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’re 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 

receive payments that aren’t 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’s your basis in a designated Roth account; the part of

premiums paid on commercial annuities or insurance contracts 

recovered tax free; the nontaxable part of a charitable gift annuity; or 

the investment in a life insurance contract reportable under section 

6050Y. This box doesn’t 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 

Form 4972. If you roll over the distribution to a designated Roth 

account in the same plan or to a Roth IRA, see the instructions for box 

2a. For a direct rollover to a designated Roth account in the same plan 

or to a Roth IRA, the NUA is included in box 2a. If you didn’t receive a 

lump-sum distribution, the amount shown is the NUA attributable to 

employee contributions, which isn’t 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 2021.

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 11, 

see the Instructions for Form 5329.

C—Reportable death benefits under section 6050Y.

D—Annuity payments from nonqualified annuities that may be subject 

to tax under section 1411.

E—Distributions under Employee Plans Compliance Resolution 

System (EPCRS). 

(Continued on the back of Copy 2)
 

Form 1099-R

2021

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, ZIP or foreign postal code, and telephone no.

PAYER’S TIN RECIPIENT’S TIN

RECIPIENT’S name

Street address (including apt. no.)

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

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

$

10 Amount allocable to IRR 

within 5 years

$

11 1st year of desig. 

Roth contrib.

12 FATCA filing 

requirement

13 Date of 

payment 

14 State tax withheld

$

$

15 State/Payer’s state no. 16 State distribution

$

$

17 Local tax withheld

$

$

18 Name of locality 19 Local distribution

$

$

Form 1099-R www.irs.gov/Form1099R
Instructions for Recipient (continued)

F—Charitable gift annuity.

G—Direct rollover of a 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 traditional IRA assets not having a readily available 

FMV.

L—Loans treated as distributions.

M—Qualified plan loan offset.

N—Recharacterized IRA contribution made for 2021 and

recharacterized in 2021.

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

earnings) taxable in 2020.

Q—Qualified distribution from a Roth IRA.

R—Recharacterized IRA contribution made for 2020 and

recharacterized in 2021.

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 section 404(k).

Note: This distribution isn’t 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’ve 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 isn’t taxable when you receive it and 

shouldn’t be included in boxes 1 and 2a. When you receive periodic 

payments from the annuity contract, they’re 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’ll 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 first year you made a contribution to the designated Roth 

account reported on this form is shown in this box.

Box 12. If checked, the payer is reporting on this Form 1099 to satisfy 

its Internal Revenue Code chapter 4 account reporting requirement 

under FATCA. You may also have a filing requirement. See the 

Instructions for Form 8938.

Box 13. Shows the date of payment for reportable death benefits 

under section 6050Y.

Boxes 14–19. If state or local income tax was withheld from the

distribution, boxes 16 and 19 may show the part of the distribution 

subject to state and/or local tax.

Additional information. You may want to see: 

Form W-4P, Form 4972, Form 5329, Form 8606

Pub. 525, Taxable and Nontaxable Income

Pub. 560, Retirement Plans for Small Business

Pub. 571, Tax-Sheltered Annuity Plans

Pub. 575, Pension and Annuity Income

Pub. 590-A, Contributions to IRAs

Pub. 590-B, Distributions from IRAs

Pub. 721, U.S. Civil Service Retirement Benefits

Pub. 939, General Rule for Pensions and Annuities

Pub. 969, HSAs and Other Tax-Favored Health Plans
 

Form 1099-R

2021

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 

2021 General

Instructions for

Certain 

Information 

Returns.

VOID CORRECTED

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

country, ZIP or foreign postal code, and telephone no.

PAYER’S TIN RECIPIENT’S TIN

RECIPIENT’S name

Street address (including apt. no.)

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

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

$

10 Amount allocable to IRR 

within 5 years

$

11 1st year of desig. 

Roth contrib.

12 FATCA filing 

requirement

13 Date of 

payment 

14 State tax withheld

$

$

15 State/Payer’s state no. 16 State distribution

$

$

17 Local tax withheld

$

$

18 Name of locality 19 Local distribution

$

$

Form 1099-R www.irs.gov/Form1099R
Instructions for Payer

To complete Form 1099-R, use: 

• The 2021 General Instructions for Certain 

Information Returns, and

• The 2021 Instructions for Forms 1099-R and 

5498.

To order these instructions and additional 

forms, go to www.irs.gov/Form1099R.

Caution: Because paper forms are scanned

during processing, you cannot file Forms 

1096, 1097, 1098, 1099, 3921, 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, 2022.

File Copy A of this form with the IRS by 

February 28, 2022. If you file electronically, the 

due date is March 31, 2022. To file 

electronically, you must have software that 

generates a file according to the specifications 

in Pub. 1220. The IRS does not provide a fill-in 

form option for Copy A.

Need help? If you have questions about

reporting on Form 1099-R, call the information 

reporting customer service site toll free at 

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).