Recipients of
Type or print | Total Distributions from

Statement for 9

PAYER'S Profit-Sharing, Retirement
Fiore, aceress: | Plans and Individual
Federal Retirement Arrangements
identifying Copy C
number For Payer’s Record
Recipient's identifying number 1 Amount includible as income 2 Capital gain (For lump-sum | 3 Ordinary income 4 Prer is paid by trustee or
(Add boxes 2, 3, and 4) distributions only) ceetoitan occurrent insarance
‘5 Employee contributions to prof- | 6 Amount of IRA distributions | 7 Category of distribution 8 Net unrealized appreciation | 9 Other:
it-sharing or retirement plans (do not include box 4 amounts) in employer's securities
$ %

This does [| does not |] qualify as a lump-sum distribution.

Your percentage of total distribution. %
Death benefit exclusion does (] or does not [] apply.

For instructions on completing this form, see ‘Instructions for
Form 1096.”

Type or print Recipient's name, address, and ZIP code above.

Form 1099R Department of the Treasury—Internal Revenue Service

Stateinent for
Recipients of 79
A type or print | Total Distributions from

PAYER'S Profit-Sharing, Retirement

name, address, ivic
ZIP code, and Plans and Individual

Federal Retirement Arrangements
identifying Copy C
number For Payer’s Record
Recipient's identifying number 1 Amount includible as income 2 Capital gain (For lump-sum | 3 Ordinary income 4 Premiums paid by trustee or
(Add boxes 2, 3, and 4) distributions only) custodian for current insurance
5 Employee contributions to prof- | 6 Amount of IRA distributions | 7 Category of distribution | 8 Net unrealized appreciation | 9 Other:
it-sharing or retirement plans (do not include box 4 amounts) in employer's securities
$ S.

This does [] does not |] qualify as a lump-sum distribution.

Your percentage of total distribution. %
Death benefit exclusion does [7] or does not [-] apply.

For instructions on completing this form, see “Instructions for
Form 1096.”

Type or print Recipient's name, address, and ZIP code above.

Form LO99R Department of the Treasury—Internal Revenue Ser

Statement for

Recipients of 79
Type or print Total Distributions from
PAYER’S Profit-Sharing, Retirement

name, address, ivi
ied ces’ | Plans and Individual

Federal Retirement Arrangements
identifying Copy C
number For Payers Record
Recipient's identifying number 1 Saget includible as income 2 Capital gain (For lump-sum | 3 Ordinary income 4 Premiums paid by trustee or
(Add boxes 2, 3, and 4) distributions only) custodian for current insurance
5 Employee contributions to prof- | 6 Amount of IRA distributions | 7 Category of distribution 8 Net unrealized appreciation | 9 Other:
it-sharing or retirement plans (do not include box 4 amounts) in employer's securities
$ %

This does [-] does not |] qualify as a lump-sum distribution.

“Your percentage of total distribution. > %
Death benefit exclusion does [_] or does not [_] apply.

For instructions on completing this form, see “‘Instructions for
Form 1096.”

Type or print Recipient's name, address, and ZIP code above.

Form 1099R Department of the Treasury—internal Revenue Servi



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WHING OFFICE : 1978 —O-205-618 S8-NIO-T.AD

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YOUS. GOMENMEN





| Statement for @)
For Official Use Only Recipients of By

A type or print | Total Distributions from
fi PAYER'S Profit-Sharing, Retirement
name, address, | Plans and Individual
ZIP code, and i
Retirement Arrangements

Federal
identifying Copy A For Internal
number Revenue Service Center
Recipient's identifying number 1 Amount includible as income 2 Capital gain (For lump-sum | 3 Ordinary income 4 Premiums paid by trustee or
(Add boxes 2, 3, and 4) distributions only) custodian for current insurance
98 F]
—.) _ -
5 Employee contributions to prof- J 6 Amount of IRA distributions § 7 Category of distribution 8 Net unrealized anpreciation 9 Other;
it-sharing or retirement plans (do not include box 4 amounts) in employer's securities
bs %
Name
For instructions on compieting this form, see “Instructions for
Type or print Recipient's name, address, and ZIP code above. (Name # Form 1096.’
must aline with arrow)
Form 1099R Department of the Treasury—Internal Revenue Service
| Statement for
For Official Use Only Recipients of
Type or print | Total Distributions from
PAYER'S Profit-Sharing, Retirement
Se ataress: Plans and Individual
Federal Retirement Arrangements
identifying Copy A For Internal
number Revenue Service Center
Recipient's identifying number 1 Amount includible as income 2 Capital gain (For tump-sum ff 3 Ordinary income 4 Premiums paid by by trustee or
(Add boxes 2, 3, and 4) distributions only) custodian for current insurance:
98 []
5 Employee contributions to prof. | 6 Amount of IRA distributions W 7 Category of distribution @ Net unrealized apoveciation #9 Other:
it-sharing or retirement plans (do not include box 4 amounts) in employer's securitie
as %
This does [] does not [~ iy as a lump-sum distribution.
Name > a]
Your percentage of total distribution. %
Death benefit exclusion does [| or does not | | apply.
For instructions on completing this form, see “Instructions for
Type or print Recipient's name, address, and ZIP code above. (Name § Form 1096.’
must aline with arrow) ; -
Form 1099R Department of the Tressury—Internal Revenue Service
{ Statement for 9
For Officia! Use Only Recipients of
Type or print Total Distributions from
PAYER'S. Profit-Shaving, Retirement
game, address, | Plans and Individual
and : A
Federal Retirement Arrangements
identifying Copy A For Internal
number Revenue Service Gonter
Recipient's identifying number 1 Amount includible as income 2 Capital gain (For iump-sum ff 3 Ordinary income 4 Premi paid by trustee or
(Add boxes 2, 3, and 4) distributions only) custodian forcurrent insurance
98 F
— =
5 Employee contributions to prof- | 6 Amount of IRA distributions J 7 Category of distribution 8B Net unrealized appreciation ‘9 Other:
it-sharing or retirement plans (do not include box 4 amounts) in employer's securities
Name >

Death benefit exclusion does [ ] or does not [ ] apply.

For instructions on compieting this form, see “Instructions for

Type or print Recipient's name, address, and Z!P code above. (Name § Form 1096.”"

must aline with arrow)

Form 1099R Department of the Treasury—tnternal Revenue Service





Statement for
Recipients of 1979

‘type or print | Total Distributions from

PAYER'S Profit-Sharing, Retirement
same, address: | Plans and Individual
IP code, and "
Fede Retirement Arrangements
Federal
identifying Copy B
number For Recipient
1 Amoant includible as income | 2 Capital or tum 3 Ordinary in Premi id by tru
feaarteacetseneges geome |? Gama ae ony umes any income “ Clstodin fercurrent insurance
5 Employee eo: & Amount of {RA dist batons | 7 Category of distribution | & Net unrealized appreciation | 9 Other:
it-sharing (do not include box 4 amounts’ in employer's securities |
i _— $ %
This does (~] does not |] qualify as 4 lump-sum distribution.
Your percentage of total distribution. B %
Death beneiit exclusion does [_] or does not |] apply.
For instructions on completing this form, see “instructions for
Type or print Recipieni’s name, address. and ZIP code above. | This information is being furnished to the internal Revenue Service.
Form LOSER Department of the Treasury~Internal Revenue Service
Statement for
_ Recipients of
‘type or print | Total Distributions from
PAYER'S Profit-Sharing, Retirement
sarre, aceress: | Plans and Individual
Federal Retirement Arrangements
identifying Copy B
number For Recipient
Recipient’, fying number | L Amount includible as income | 2 Capital gain (For lump-sum | 3 Ordinary income 4 Premiums paid by trustee or
(Add boxes 2, 3, and 4) distributions only) custodian for current insurance:

ibutions fo py

retirement plan

IA dlsibaions | 7 Cateaon of Gistribution
inv employer's securities
i

3 Net unrealized appreciation / Other: |

3 %
| This does [| does not |} qualify as a lump-sum distribution.

Your percentage of total distribution. > %
Death benefit exclusion does (-] or does not {_) apply.
For instructions on completing this form, see “Instructions for
Form 1096."
Type or print Recipient's name, address, and ZIP cede above. This information is being furnished to the Internal Revenue Service.
Forin LOS9R Department of the freasury—Internal Revenue Service

Statement for
Recipients of 79
Type or print | Total Distributions from

PAYER’S Profit-Sharing, Retirement
name, address, | Plans and Individual

ZIP code, and .
fata” | Retirement Arrangements
identifying Copy B
- . number For Recipient
ven |e soni iniglitie ag ome] Capital enn (For lump-sum | 3 Orinary income @ Premiums paid by trustee or
#2, 4, and 4} distributions only) custodian for current insurance:

| 7 Category of distribution
{ in omployer's securities

Unrealized appreciation | 9 Other: |

- i $s %
ee a This does [] does not |] qualify as a lump-sum distribution.
|_Your percentage of total distribution. > %

Death benefit exclusion does [_] or does not |_] apply.

For instructions on completing this form, see “instructions for
Form 1096.”
This information is being furnished to the Internal Revenue Service.

Department of the Treasury—Internal Revenue Service