‘Statement for

1978

Recipients of
Type or print | Total Distributions from
PAYER'S: Profit-Sharing, Retirement
sires ateress: | Plans and Individual
Federal Retirement Arrangements
identifying Copy C

umber For Payer’s Record

Recipient's identifying number | 1 Amount includible as income | 2 Capital gain (For lump-sum
(Add distributions only)

boxes 2, 3, and 4)

3 Ordinary income 4 Premiums paid by trustee or

Custodian for current insurance

‘5 Employee contributions to prof- | 6 Amount of IRA distributions
it-sharing or retirement plans | (do not include box 4 amounts)

7 Category of distribution

& Net unrealized appreciation | 9 Other
in employer's securities

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

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

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

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

Form 1099R

sk GPO :1977-O-235-10525-1116272

Department of the Treasury—Internal Revenue Service

1978

Statement for
Recipients of

‘Type or print | Total Distributions from
PAYER'S Profit-Sharing, Retirement
game, address, | Plans and Individual
Federal oe Retirement Arrangemenis
identifying Copy C

number For Payer's Record

Recipient's identifying number | 1 Amount includible as income
(Add boxes 2, 3, and 4)

gain (For lump-sum | 3 Ordinary income
butions only)

4 Premiums paid by trustee or
‘ustodian forcurrent insurance

‘5 Employee contributions to prof- | 6 Amount of IRA distributions | 7 Category of distribution

it-sharing or retirement plans | (do not include box 4 amounts)

® Net unrealized appreciation | 9 Other:
in employer's securities

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

$ %
This does [-] does not |] qualify as a lump-sum distribution.
Your percentage of total distribution. D> %

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

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

Form 1099R

Ye GPO :1977-0-235-105 25-1118272

Department of the Treasury—Internal Revenue Service

1978

Statement for

Recipients of

Type or print | Total Distributions from
PAYER'S Profit-Sharing, Retirement
game. address, | Plans and Individual
fajaal "” | Retirement Arrangements
identifying Copy C

number For Payer’s Record

Recipient's identiying oumber | 2 Amount inladible a5 income

id boxes 2, 3, and 4)

gain (For lump-sum | 3 Ordinary income
‘butions only)

4 Premiums paid by trustee or
Custodian for current insurance

5 Employee contributions to prof- | 6 Amount of IRA distributions
it-sharing or retirement plans | (do not include box 4 amounts)

7 Category of distribution

& Net unrealized appre
in employer's securiti

tion | 9 Other:

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

$ %
This does [_] does not [ ] qualify as a lump-sum distribution.
Your percentage of total distribution. D> %.

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

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

Form 1099R

Ye GPO :1977-O-235-105 25-1110272

Department of the Treasury—Internal Revenue Service


Notice to Recipients:
(References are to the Internal Revenue Code.)

These instructions apply to distributions from prof-
it-sharing and retirement plans, with the exception
of boxes 6 and 7 (for individual retirement arrange-
ments) and box 4 which may apply to any distribution.

Lump-sum Distribution —Generally the term “Iump-
sum distribution” means the distribution or payment,
from a retirement plan, within one taxable year of the
receipt, of tne balance to the credit of an individual
which becomes payable to the recipient (a) on ac-
count of death, (b) after attaining age 5912, (c) sep-
aration from the service, or (d) becoming disabled
(within the meaning of section 72(m)(7)).

If the distribution does not qualify as a lump-sum
distribution, no portion qualifies for capital gain treat-
ment. The special 10-year averaging method does not
apply. In such case, report the total amount of the
distribution on Form 1040 under Other Income. For
additional information, see Publication 575.

Box 2.—This portion of the lump-sum distribution
qualifies for capital gain treatment. Report on Sched-
ule D (Form 1040 or Form 1041) and identify as
“Lump-sum Distribution.” See Death Benefit Exclu-
sion below. Also see instructions for Form 4972 or

Notice to Recipients:
(References are to the Internal Revenue Code.)

These instructions apply to distributions from prof-
it-sharing and retirement plans, with the exception
of boxes 6 and 7 (for individual retirement arrange-
ments) and box 4 which may apply to any distribution.

Lump-sum Distribution.—Generally the term “iump-
sum distribution” means the distribution or payment,
from a retirement plan, within one taxable year of the
receipt, of the balance to the credit of an individual
which becomes payable to the recipient (a) on ac-
count of death, (b) after attaining age 591%, (c) sep-
aration from the service, or (d) becoming’ disabled
(within the meaning of section 72(m)(7)).

If the distribution does not qualify as a lump-sum
distribution, no portion qualifies for capital gain treat-
ment. The special 10-year averaging method does not
apply. In such case, report the total amount of the
distribution on Form 1040 under Other Income. For
additional information, see Publication 575,

Box 2.--This portion of the lump-sum distribution
qualifies for capita! gain treatment. Report on Sched-
ule D (Form 1040 or Form 1041) and identify as
“Lump-sum Distribution.” See Death Benefit Exclu-
sion below. Also see instructions for Form 4972 or

Notice to Recipients:
(References are to the Internal Revenue Code.)

These instructions apply to distributions from prof-
it-sharing and retirement plans, with the exception
of boxes 6 and 7 (for individual retirement arrange-
ments) and box 4 which may apply to any distribution.

Lump-sum Distribution.—Generally the term “‘lump-
sum distribution” means the distribution or payment,
from a retirement plaa, within one taxable year of the
receipt, of the balance to the credit of an individual
which becomes payable to the recipient (a) on ac-
count of death, (b) after attaining age 591%, (c) sep-
aration trom the service, or (d) becoming’ disabled
(within the meaning of section 72(m)(7)).

If the distribution does not qualify as a lump-sum
distribution, no portion qualifies for capital gain treat-
ment. The special 10-year averaging method does not
apply. In such case, report the total amount of the
distribution on Form 1040 under Other Income. For
additional information, see Publication 575.

Box 2.—This portion of the lump-sum distribution
qualifies for capital gain treatment. Report on Sched-
ule D (Form 1040 or Form 1041) and identify as
“Lump-sum Distribution.” See Death Benefit Exclu-
‘sion below. Also see instructions for Form 4972 or

5544 for election to treat this amount as ordinary
income for the 10-year averaging method.

Box 3.—This portion of the total distribution is
taxable as ordinary income and may be eligible for
a special 10-year averaging method. See Form 4972
or 5544 and instructions for death benefit exclusion
below.

Note: If there are no entries in boxes 2 and 3,
ask tne employer to furnish them.

Box 4.—Keport this amount cn Form 1040 under
Other Income as “Premiums paid by trustee or cus-
todian for current life or other insurance.”

Box 5.-—Amounts contributed or considered con-
tributed by the individual (!ess nontaxable amounts
previously distributed) are nct taxable.

Note: se boxes only if you are re-
porting IRA ‘distributions:

Box 6.— Amounts you received as distribu-
tions from an Individual Retirement Account,
Annuity or Bond.

Box 7.—Identify the type of distributions
using the following code aumbers:

1—Premature Distribution (other than codes
2, 3, 4, or 5); 2—Rollover; 3—Disability; 4—
Death; "S-—Plohibited Transaction; 6—Other,
7—Normal Distribution.

‘fe US, GOVERNMENT PRINTING OFFICE : 197-—-- 235-105

5544 for election to treat this amount as ordinary
income for the 10-year averaging method.

Box 3.—This portion of the total distribution is
taxable as ordinary income and may be eligible for
a special 10-year averaging method. See Form 4972
or 5544 and instructions for death benefit exclusion
below.

Note: If thera are no entries in boxes 2 and 3,
ask the employer to furnish them.

Box 4.—Report this amount on Form 1040 under
Other Income as “Premiums paid by trustee or cus-
todian for current life or other insurance.”

Box 5.—Amounts contributed or considered con-
tributed by the individual (less nontaxable amounts
previously distributed) are not taxable.

Noto: Use these boxes only it you are re-
porting IR) rib

Bor 6-—Amounts you received as datrbu-
tions from an Individual Retirement Account,
Annuity or Bond.

Box 7.—Identify the type of distributions
using the following code numbers:

1—Premature Distribution (other than codes
2, 3, 4, of Rollover; 3—Disability; 4—
Death; 5—Prohibited Transaction; 6—Other;
7—Normal Distribution.

Ye US. GOVERNMENT PRINTING OFFICE : 1977-O-238-105 2

5544 for election to treat this amount as ordinary
income for the 10-year averaging method.

Box 3.—This portion of the total distribution is
taxable as ordinary income and may be eligible for
a special 10-year averaging method. See Farm 4972
or 5544 and instructions for death benefit exclusion
below.

Note: If there are no entries in toxes 2 and 3,
ask the employer to furnish them.

Box 4.—Report this amount on Form 1040 under
Other Income as “Premiums paid by trustee or cus-
todian for current life or other insurance.”

Box 5.—Amounts contributed or considered con-
tributed by the individual (less nontaxable amounts
previously distributed) are not taxable.

boxes only if you are re-
potting IRA ‘dit tributions.

Box 6.—Amounts you “received as distribu-
tions from an Individual Retirement Account,
Annuity or Bon

Box 7. tify the type of distributions
using the following code numbers:

1--Premature ribution (other than codes
2, 3, 4, or 5); Rollover; 3—Disability; 4—
Death; 5—Prohibited Transaction; 6—Other;
7—Nomal Distribution.

‘yy US. GOVERNMENT PRINTING OFFICE : 1577—O-235-105

Box 8.—If the distribution consists in part of secu-
tities of your employer's corporation, the net unreal-
ized appreciation in these securities is tax deferred
until you sell the securities.

Annuity.—If you receive an annuity contract as part
of a distribution, it is not taxable upon receipt. It is
taxable when periodic payments are received, but only
to the extent the payments exceed your basis in the
annuity. If the distribution is made to more than one
person, the dollar amount and the percentage of the
annuity contract distributed to you is shown in box 9.
You will need that information if you elect the speciai
10-year averaging method on Form 5544,

Death Benefit Exclusion.—If you receive a plan dis-
tribution as the beneficiary of a deceased employee
(or deceased disability retiree who died prior to at-
taining retirement age) you may be entitled to 2
“death benefit exclusion” of up to $5,090.

Taxable amounts shown in boxes 2 and 3 are with-
out regard to this exclusion. Allocate the exclusion be-
tween capital gain and ordinary income and include
the reduced amounts on your tax return.

Note: If the total distribution is made to more
than one person, the percentage you received is
shown in the space below box 9. Enter the percentage
‘on line 1, Form 5544, Multiple Recipient Special
10-Year Averaging Method, if elected.

aseitiea72

Box 8.—If the distribution consists in part of secu-
tities of your employer's corporation, the net unreal-
ized appreciation in these securities is tax deferred
until you sell the securities.

Annuity.—If you receive an annuity contract as part
of a distribution, it 1s not taxable upon receipt. tt is
taxable when periodic payments are received, but only
to the extent the payments exceed your basis in the
annuity. If the distribution is made to more than one
person, the dollar amount and the percentage of the
annuity contract distributed to you is shown in box 9.
You will need that information if you elect the special
10-year averaging method on Form 5544.

Death Benefit Exclusion.—If you receive a plan dis-
tribution as the beneficiary of a deceased employee
(or deceased disability retiree who died prior to at-
taining retirement age) you may be entitled to a
“death benefit exclusion” of up to $5,000.

Taxable mounts shown in boxes 2 and 3 are with-
out regard {co this exclusion. Allocate the exclusion be-
tween capital gain and ordinary income and include
the reduced amounts on your tax return.

Note: If the total distribution is made to more
than one person, the percentage you received is
shown in the space below box 9. Enter the percentage
‘on line 1, Form 5544, Multiole Recipient Special
10-Year Averaging Method, if elected.

e272

Box 8.—Iif the distribution consists in part of secu-
tities of your employer's corporation, the net unreal-
ized appreciation in these securities is tax deferred
until you sell the securities.

Annuity.—If you receive an annuity contract as part
of a distribution, it 1s not taxable upon receipt, It is
taxable when periodic payments are received, but only
to the extent the payments exceed yaur basis in the
annuity. If the distribution is made to more than one
person, the dollar amount and the percentage of the
anauity contract distributed to you is shawn in box 9.
You will need that information if vou elect the special
10-year averaging method on Form 5544.

Death Benefit Exclusion.—If you receive a plan dis-
tribution as the beneficiary of a deceased employee
(or deceased disability retiree who died prior to at-
ining retirement age) you may be entitled to a
“death benefit exclusion” of up t0 $5,000.

Taxable amounts shown in boxes 2 and 3 are with-

out regard to this exclusion. Allocate the exclusicn be-
tween capital gain and ordinary income and include
the reduced amounts on your tax return.
: If the total distribution is made to more
person, the percentage you received is
shown in the space below box 9. Enter the percentage
on line 1, Form 5544, Multiple Recipient Special
10-Year Averaging Method, if elected.

28-1110272


For Official Use Only

Statement for

Recipients of 1978

Type or print Total Distributions from

PAYER'S. Profit-Sharing, Retirement
saa address: Plans and Individual
Federal Retirement Arrangements
identifying Copy A For Internal

number

8

Name

87

Name >|

Recipient's identifying number J 1 Amount includible as income

(Add boxes 2, 3, and 4) distributions only)

2 Capital ain (For lump-sum

Revenue Service Center

4 Premiums paid by trustee or
custadian for current insurance

3 Ordinary income

'5 Employee contributions to prof- J 6 Amount of IRA distributions | 7 Category of distribution & Net unrealized appreciation | 9 Other.
it-sharing or retirement plans (do not include box 4 amounts) in employer's securities |
i
s tw
This does [_] does not [_] qualify as a lump-sum distribution.

Your percentage of total distribution. > %.

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

Type or print Recipient’s name, address, and ZIP code above. (Name
must aline with arrow)

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

Form 1099R

For Official Use Only

Department of the Treasury-—internal Revenue Service
Statement for

Recipients of 1978

Total Distributions from
Profit-Sharing, Retirement
Plans and Individual
Retirement Arrangements
Copy A For Internal
Revenue Service Center

Type or print
PAYER'S
name, address,
ZIP code, and
Federal
identifying
number

Fecinlent’sIdentlfing wurmber | 1) Aisoore elude 46 insams

boxes 2, 3, and 4)

2 Capital gain (For lump-sum
distributions only)

3 Ordinary income ums paid by trustee or

custodian for current insurance

5 Employee contributions to prof-
itsharing or retirement plans

@ Amount of IRA distributions
(do not include box 4 amounts)

7 Category of distribution

® Net unrealized appreciation | 9 Other:

in employer's securities

s %

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

Your percentage of total distribution. y

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

Type or print Recipient's name, address, and ZIP code above. (Name
must aline with arrow)

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

Form 1099R

For Official Uso Only

Department of the Treasury—Internal Revenue Servi
Statement for

Recipients of 1978

Type or print | Total Distributions from

PAYER’S. Profit-Sharing, Retirement
Bienes adress Plans and Individual
Federal Retirement Arrangements
identifying Copy A For Internal

number

Revenue Service Center

Name P|

Recipient's identifying number J 1 Amount includible as income

(Add boxes 2, 3, and 4)

2 Capital gain (For lump-sum
distributions only)

4 Promiums paid by trustee or

3 Ordinary income
custodian forcurrent insurance

9 Other:

5 Employee contributions to prof- 6 Amount of IRA distributions J 7 Category of distribution 8 Net unrealized appreciation
it-sharing or retirement plans (do not include box 4 amounts) in employer's securities |
3 | %
This does [] does not |] qualify as a lump-sum distribution.

Your percentage of total distribution. DP Yo.

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

Type or print Recipient's name, address, and ZIP code above. (Name
must aline with arrow)

For instructions on completing this form, see “‘Instructions for

Form 1096.

Form 1099R

Department of the Treasury—Internal Revenue Service




‘Statement for

recnensot — 1948

Type or print Total Distributions from

PAYER’S: Profit-Sharing, Retirement
game. address. | Plans and Individual
Federal Retirement Arrangements
identifying Copy B

number

For Recipient

Recipient's identifying number

1 Amount includible as income
(Add boxes 2, 3, and 4)

2 Capital gain (For lump-sum
distributions only)

3 Ordinary income 4 Promiums paid by trustee or

custodian for current insurance

5 Employee contributions to prof.
it-sharing or retirement plans

6 Amount of IRA distributions
(do not include box 4 amounts)

B Net unrealized appreciation | 9 Other:

in employer's securities

7 Category of distribution

s %

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

This does [] does not |] quality 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.

Form 1099R

Department of the Treasury—Internal Revenue Service
Statement for

Recipients of 1978

Total Distributions from
Profit-Sharing, Retirement
Plans and Individual
Retirement Arrangements
Copy B

For Recipient

Type or print
PAYER'S.
name, address,
ZIP code, and
Federal
identifying
number

Recipient's identifying number

1 Amount includible as income
(Add boxes 2, 3, and 4)

4 Premiums paid by trustee or

2 Capital gain (For lump-sum
custodian for current insurance

distributions only)

3 Ordinary income

'5 Employee contributions to prof.
it-sharing of retirement plans

6 Amount of IRA distributions
(do not include box 4 amounts)

7 Category of distribution B Net unrealized appreciation | 9 Other

in employer's securities

3 %

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

This does ["] does not |] quality 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.

Form 1099R

Department of the Treasury—Internal Revenue Service
Statement for

Recipients of 1978

Type or print | Total Distributions from

PAYER'S Profit-Sharing, Retirement
Same. address. | Plans and Individual
Federal Retirement Arrangements
identifying Copy B

number

For Recipient

Recipient's identifying number

1 Amount includible as income
(Add boxes 2, 3, and 4)

2 Capital gain (For lump-sum
distributions only)

3 Ordinary income 4 Promiums paid by trustee or

custodian forcurrent insurance

5 Employee contributions to prof
it-sharing or retirement plans

Amount of IRA distributions
(do not include box 4 amounts)

7 Category of distribution @ Net unrealized appreciation | 9 Other:

in employer's securities

$ %

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

This does [-] does not |] quality 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.

Form 1099R

Department of the Treasury—Internal Revenue Service