(CI CORRECTED (if checked)

PAYER’S name, street address, city, state, and ZIP code 1 Gross distribution ‘OMB No. 1545-0119 |Total Distributions From
$ Profit-Sharing,
Retirement Plans,
2 Taxable amount an Y *
1988 Individual Retirement
$ Arrangements,
Statement for Insurance
'3 Amount in Box 2 eligible for | Recipients of Contracts, Etc.
PAYER’S Federal identification number | RECIPIENT'S identification number capital gam election 4 Federal income tax withheld
$ £ Copy B
RECIPIENT'S name (first, middle, last) 5 Employee contributions or 6 Net unrealized appreciation . Py
insurance premiums. in employer's securities For Recipient
$ $
Street address 7 Category of distribution _
This information
c p is being furnished
ity, state, and ZIP code 8 Other 9 Your percentage to the Internal
$ %| distribution % Revenue Service.
Account number (optional) 10 State income tax withheld 1 Payer's state number
$
Form 1099-R Department of the Treasury - Internal Revenue Service

(CORRECTED (if checked)

PAYER'S name, street address, city, state, and ZIP code 1 Gross distribution OMB No. 1545-0119 |Total Distributions From
. $ Profit-Sharing,
2 Taableamount Retirement Plans,
Individual Retirement
$ Arrangements,
Statement for Insurance
3 Amount in Box 2eligible for | Recipients of Contracts, Etc.
ital gain electi
PAYER'S Federal dentification number | RECIPIENT'S identification number capital gain election 4 Federal income tax withheld
§ $ Copy B
RECIPIENT'S name (first, middle, last) 5 Employee contributions or —_| 6 Net unrealized appreciation y
insurance premiums. in employer's securities For Recipient
$ $
Street address 7 Category of distribution

This information
is being furnished

City, state, and ZIP code 8 Other 9 Your percentage to the Internal
- $ %|__ distribution %_] Revenue Service.
Account number (optional) 10 State income tax withheld 1 Payer’s state number
$
Form 1099-R Department of the Treasury - Internal Revenue Service

([] CORRECTED (if checked)

PAYER’S name, street address, city, state, and ZIP code 1 Gross distribution ‘OMB No. 1545.0119 | Total Distributions From
$ R Profit-Sharing,
etirement Plans,
2 Taxable amount 1 988 Individual Retirement
$ Arrangements,
Statement for Insurance
3 Amount in Box 2 eligible for | Recipients of Contracts, Etc.
PAYER’S Federal identification number | RECIPIENT'S identification number capital gain election 4 Federal income tax withheld
RECIPIENT'S : 8 Copy B
name (first, middie, last) 5 Employee contributions or _| 6 Net unrealized appreciation
insurance premiums in employer's securities For Recipient
$ $
Street address 7 Category of distribution
This information
is being furnished
City, state, and ZIP code 8 Other 9 Your percentage to the Internal
$ %|__ distribution %_| Revenue Service.
Account number (optional) 10 State income tax withheld 1 Payer's state number
$

Form 1099-R Department of the Treasury - Internal Revenue Service






Eligible Rollover Distribution. —If this is an eligible rollover distribution, the plan
administrator is required to furnish to you an explanation of the rollover provisions of
the law and, if applicable, the 5-year/10-year averaging provisions. Each of these
provisions could affect the amount of tax you pay on this distribution. See Publication
575, Pension and Annuity Income, for more information about these provisions.
IRAs.—For distributions from an individual retirement arrangement (IRA) or simplified
employee pension (SEP), generally the payer is not required to compute the taxable
amount. Therefore, the amounts in Boxes 1 and 2 may be the same. See Publication
590, Individual Retirement Arrangements (IRAs), and Form 8606, Nondeductible (RA
Contributions, IRA Basis, and Nontaxable IRA Distributions, to determine the taxable
amount

Death Benefit Exclusion. —if you receive a plan distribution as the beneficiary of a
deceased employee, you may be entitled to a “death benefit exclusion” of up to
$5,000. See Publication 575,

Excess Distributions. —f the amount you received is more than $112,500, you may
owe an excise tax. See Form 5329, Return for Individual Retirement Arrangement and
Qualified Retirement Plans Taxes.

Box 1.—The total amount of the distribution. Distributions included in Box 8 generally
will not be included in Box 1

Box 2.—This part of the distribution is generally taxable and may be eligible for a
special 5-year/10-year averaging method. See Form 4972, Tax on Lump-Sum
Distributions, for more information. 5-year/10-year averaging does not apply to IRAs.
Note: /f there is an entry in Box 1, but no entry in Box 2, ask the payer to furnish the
information for Box 2.

Box 3.—You may be able to elect to treat this part of the distribution as a capital gain.
See the instructions for Form 1040 for information about this distribution.

Box 4.—This is the amount of Federal income tax withheld on the distribution
reported on this form. Include this on your income tax return as tax withheld.

Box 5.—Amounts contributed or considered contributed by the individual that were
not deductible by the individual when the contribution was made (minus nontaxable

Eligible Rollover Distribution. —If this is an eligible rollover distribution, the plan
administrator is required to furnish to you an explanation of the rollover provisions of
the law and, if applicable, the 5-year/10-year averaging provisions. Each of these
provisions could affect the amount of tax you pay on this distribution. See Publication
575, Pension and Annuity Income, for more information about these provisions.
IRAs.—For distributions from an individual retirement arrangement (IRA) or simplified
‘employee pension (SEP), generally the payer is not required to compute the taxable
amount, Therefore, the amounts in Boxes 1 and 2 may be the same. See Publication
590, individual Retirement Arrangements (IRAs), and Form 8606, Nondeductible IRA
Contributions, IRA Basis, and Nontaxable IRA Distributions, to determine the taxable
amount

Death Benefit Exclusion. —If you receive a plan distribution as the beneficiary of a
deceased employee, you may be entitied to a “death benefit exclusicn” of up to
$5,000. See Publication 575.

Excess Distributions. —if the amount you received is more than $112,500, you may
owe an excise tax. See Form 5329, Return for Individual Retirement Arrangement and
Qualified Retirement Plans Taxes.

Box 1.—The total amount of the distribution. Distributions included in Box 8 generally
will not be included in Box 1

Box 2.—This part of the distribution is generally taxable and may be eligible for a
special 5-year/10-year averaging method. See Form 4972, Tax on Lump-Sum
Distributions, for more information. 5-year/10-year averaging does not apply to IRAs.
Note: if there is an entry in Box 1, but no entry in Box 2, ask the payer to furnish the
information for Box 2.

Box 3.—You may be able to elect to treat this part of the distribution as a capital gain
See the instructions for Form 1040 for information about this distribution.

Box 4.—This is the amount of Federal income tax withheld on the distribution
reported on this form. Include this on your income tax return as tax withheld.

Box 5.—Amounts contributed or considered contributed by the individual that were
not deductible by the individual when the contribution was made (minus nontaxable

Eligible Rollover Distribution. —if this is an eligible rollover distribution, the plan
administrator is required to furnish to you an explanation of the rollover provisions of
the law and, if applicable, the 5-year/10-year averaging provisions. Each of these
provisions could affect the amount of tax you pay on this distribution. See Publication
575, Pension and Annuity Income, for more information about these provisions.
IRAs.—For distributions from an individual retirement arrangement (IRA) or simplified
employee pension (SEP), generally the payer is not required to compute the taxable
amount. Therefore, the amounts in Boxes 1 and 2 may be the same. See Publication
590, Individual Retirement Arrangements (IRAs), and Form 8606, Nondeductible IRA
Contributions, IRA Basis, and Nontaxable IRA Distributions, to determine the taxable
amount.
Death Benefit Exclusion.—If you receive a plan distribution as the beneficiary of a
deceased employee, you may be entitled to a “death benefit exclusion” of up to
$5,000. See Publication 575.
Excess Distributions.—If the amount you received is more than $112,500, you may
owe an excise tax. See Form 5329, Return for Individual Retirement Arrangement and
Qualified Retirement Plans Taxes
Box 1.—The total amount of the distribution. Distributions included in Box 8 generally
will not be included in Box 1
Box 2.—This part of the distribution is generally taxable and may be eligible for a
special 5-year/10-year averaging method. See Form 4972, Taxon Lump-Sum
Distributions, for more information. 5-year/10-year averaging does not apply to IRAs.
Note: /f there 1s an entry in Box 1, but no entry in Box 2, ask the payer to furnish the
information for Box 2.
You may be able to elect to treat this part of the distribution as a capital gain.
instructions for Form 1040 for information about this distribution.
This is the amount of Federal income tax withheld on the distribution
reported ‘on this form. Include this on your income tax return as tax withheld.

}ox 5.—-Amounts contributed or considered contributed by the individual that were
not deductible by the individual when the contribution was made (minus nontaxable

amounts previously distributed) are not taxable to the individual when distributed. This
box will not show any contributions to an IRA or SEP but will show premiums paid on
commercial annuities or insurance contracts.

Box 6.—If the distribution consists in part of securities of your employer's corporation,
and the distribution 1s a lump-sum distribution, the net unrealized appreciation in these
securities 1s taxed only when you sell the securities unless you elect otherwise

Box 7.—No code may be present if the amount in Box 1 1s a normal distribution from a
plan other than an IRA or SEP. The code(s) listed identifies the distribution you
received, as follows:

1—Premature distribution (other than codes 2, 3, 4, 5, 8, or P; see Form 5329);
2—Rollovers; 3—Disability; 4—Death (includes payments to a beneficiary);
5—Prohibited transactions; 6—Other, 7—Normal IRA or SEP distributions;
8—Excess contributions/deferrals refunded plus earnings taxable in 1988; 9—PS 58
costs; P—Excess contributions /deferrals refunded plus earnings taxable in 1987.
A—Qualifies for 5-year/10-year averaging; B—Qualifies for death benefit exclusion;
C—Qualifies for both A and B

Box 8.—If you receive an annuity contract as part of a distributign, the value of the
contract is not taxable when you receive it. When you receive periodic payments from
‘the annuity contract, they are taxable at that time. If the distribution 1s made to more
than one person, the dollar amount and the percentage of the annuity contract
distributed to you are shown in this box. You will need this information if you elect the
special 5-year/10-year averaging method.

If an annuity contract has been transferred to another trustee, an amount will be
shown in this box and Code 2 will be shown in Box 7.

If you receive a death benefit payment that is not part of a pension, profit-sharing, or
retirement plan as a beneficiary from the employer of a deceased employee, the
amount will be shown in this box and Code 4 will be shown in Box 7. See Publication
525, Taxable and Nontaxable Income.

Box 9.—If the total distribution 1s made to more than one person, the percentage you
received is shown here.

amounts previously distributed) are not taxable to the individual when distributed. This

box will not show any contributions to an IRA or SEP but will show premiums paid on

commercial annuities or insurance contracts

Box 6.—If the distribution consists in part of securities of your employer's corporation,

and the distribution is a lump-sum distribution, the net unrealized appreciation in these

securities 1s taxed only when you sell the securities unless you elect otherwise.

Box 7.—No code may be present if the amount in Box 1 1s a normal distribution from a

plan other than an IRA or SEP. The code(s) listed identifies the distribution you

received, as follows:

1_Premature distribution (other than codes 2, 3, 4, 5, 8, or P; see Form 5329);

2—Rollovers; 3— Disability; 4—Death (includes payments to a beneficiary);

— Prohibited transactions; 6—Other; 7—Normal IRA or SEP distributions;

‘8—Excess contributions/deferrals refunded plus earnings taxable in 1988; 9—PS 58

gosts; P_Excess contributions /deferrals refunded plus earnings taxable in 1987;
AGuaites for 5-year/10-year averaging; B— Qualifies for death benefit exclusion;

ualifies for both A and B.
box 8.—If you receive an annuity contract as part of a distribution, the value of the
contract is not taxable when you receive it. When you receive periodic payments from
the annuity contract, they are taxable at that time. If the distribution 1s made to more
than one person, the dollar amount and the percentage of the annuity contract
distributed to you are shown in this box. You will need this information if you elect the
special 5-year/ 10-year averaging method.

If an annuity contract has been transferred to another trustee, an amount will be
shown in this box and Code 2 will be shown in Box 7.

If you receive a death benefit payment that 1s not part of a pension, profit-sharing, or
retirement plan as a beneficiary from the employer of a deceased employee, the
amount will be shown in this box and Code 4 will be shown in Box 7. See Publication
525, Taxable and Nontaxable Income.

Box 9.—If the total distribution is made to more than one person, the percentage you
received is shown here,

amounts previously distributed) are not taxable to the individual when distributed. This
box will not show any contributions to an IRA or SEP but will show premiums paid on
commercial annuities or insurance contracts.
Box 6,—If the distribution consists in part of securities of your employer's corporation,
and the distribution is a lump-sum distribution, the net unrealized appreciation in these
securities is taxed only when you sell the securities unless you elect otherwise
Box 7.—No code may be present if the amount in Box 1 1s a normal distribution from a
plan other than an IRA or SEP. The code(s) listed identifies the distribution you
received, as follows:
1—Premature distribution (other than codes 2, 3, 4, 5, 8, or P; see Form 5329);
2—Rollovers; 3—Disability; 4—Death (includes payments to a beneficiary);
5—Prohibited transactions; 6—Other; 7—Normal IRA or SEP distributions;
8—Excess contributions/deferrals refunded plus earnings taxable in 1988; 9—PS 58
costs; P—Excess contributions/deferrals refunded plus earnings taxable n 1987;

\— Qualifies for 5-year/10-year averaging; B—Qualifies for death benefit exclusion;
C—Qualifies for both Aand B.
Box 8.—If you receive an annuity contract as part of a distribution, the value of the
contract is not taxable when you receive it, 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 dollar amount and the percentage of the annuity contract
distributed to you are shown in this bex. You will need this information if you elect the
special 5-year/10-year averaging method

If an annuity contract has been transferred to another trustee, an amount will be
shown in this box and Code 2 will be shown in Box 7.

If you receive a death benefit payment that is not part of a pension, profit-sharing, or
retirement plan as a beneficiary from the empioyer of a deceased employee, the
amount will be shown in this box and Code 4 will be shown in Box 7 See Publication
525, Taxable and Nontaxable Income
Box 9.—If the total distribution 1s made to more than one person, the percentage you
received is shown here.



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[J CORRECTED

PAYER'S name, street address, city, state, and ZIP code

1 Gross distribution

OMB No. 1545-0119

PAYER'S Federal identification number

RECIPIENT'S identification number

Total Distributions From

RECIPIENT'S name (first, middle, last)

Street address

$ Profit-Sharing,

Retirement Plans,

2 Taxable it et . H

aanieamoun 1988 Individual Retirement

$ Arrangements,

Statement for Insurance

‘3 Amount in Box 2 eligible for Recipients of Contracts, Etc.
capital gain election 4 Federal income tax withheld

Copy C

§ $ For Payer
5 Employee contributions or | 6 Net unrealized appreciation

insurance premiums in employer's securities For Paperwork

Reduction Act

$ $ Notice and

7 Category of distribution

instructions for
completing this

form, see

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of total

$ %|__ distribution % Forms 1099,

1098, 5498,

Account number (optional)

[10 State income tax withheld

$

fit Payer's state number

1096, and W-2G.

Form 1099-R

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Department of the Treasury - Internal Revenue Service

PAYER’S name, street address, city, state, and ZIP code

1 Gross distribution

OMB No. 1545-0119

Total Distributions From
Profit-Sharing,

$
Retirement Plans,
2 Taxabl t Y 4
aranieameun 1988 Individual Retirement
$ Arrangements,
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$ $
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form, see
City, state, and ZIP code 8 Other 9 Your percentage Instructions for
of total
: $ % | distribution % roms 1989.
Account number (optional) - State income tax withheld t1 Payer's state number 1096. and W.-2G.

Form 1099-R

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Department of the Treasury - Internal Revenue Service

PAYER'S name, street address, city, state, and ZIP code

1 Gross distribution

$

2 Taxable amount

$

1988

Statement for

PAYER'S Federal identification number

RECIPIENT'S identification number

capital gain election’

$

3 Amount in Box 2 eligible for

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OMB No. 1545-0119

Total Distributions From
Profit-Sharing,
Retirement Plans,
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Arrangements,
Insurance

Contracts, Etc.

$

4 Federal income tax withheld

Copy C

RECIPIENT'S name (first, middle, last)

Street address

City, state, and ZIP code

5 Employee contributions or
insurance premiums

$

$

6 Net unrealized appreciation
in employer's securities

For Payer

For Paperwork
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Notice and

7 Category of distribution

instructions for
completing this

8 Other

$

9 Your percentage
of total

% |__distribution

form, see
Instructions for
Forms 1099,

Account number (optional)

[10 State income tax withheld

$

1 Payer's state number

1098, 5498,
1096, and W-2G.

Form 1099-R

Department of the Treasury - Internal Revenue Service


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For Official Use Only,

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1 Gross distribution

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Form 1099-R Do NOT Cut or Separate Forms on This Page pari © Treasury «Internal Revenue Service
9a98 [voip [| CORRECTED For Official Use Only

‘Type or machine print PAYER'S name, street address, city, state, and ZIP code | 1 Gross distribution ‘OMB No. 1545.0119 |Total Distributions From
$ Profit- Sharing,

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$ 1096, and W-2G.

Form 1099-R

Department of the Treasury - Internal Revenue Service

Do NOT Cut or Separate Forms on This Page

9498 (voip

(C1) CORRECTED

For Official Use Only

‘Type or machine print PAYER’S name, street address, city, state, and ZIP code

1 Gross distribution

$

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2 Taxable amount

1988

otal Distributions From
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$ 1096, and W-2G.
Form 1099-R Department of the Treasury - Internal Revenue Service


(CJ CORRECTED (if checked)

PAYER’S name, street address, city, state, and ZIP code

1 Gross distribution

Total Distributions From
Profit-Sharing,

OMB No. 1545-0119

$ 4
Retirement Plans,
2 Taxable amount 1] 9 8 8 Individual Retirement
$ Arrangements,
Statement for Insurance

PAYER’S Federal identification number | RECIPIENT'S identification number

capital gain election

$

‘3 Amount in Box 2 eligible for

Recipients of Contracts, Etc.

4 Federal income tax withheld

$

RECIPIENT'S name (frst, middle, ast) '5 Employee contributions or | 6 Net unrealized appreciation Copy 2
insurance premiums in employer's securities To be filed
with
$ $ ient’
recipient's

Street address

7 Category of distribution

state income
tax return,

City, state, and ZIP code @ Other 9 Your percentage
* of total when
$ %| distribution % required.

‘Account number (optional)

[LO State income tax withheld

$

1 Payer’s state number

Form 1099-R

Department of the Treasury - Internal Revenue Service

{LJ CORRECTED (if checked)

PAYER'S name, street address, city, state, and ZIP code

1 Gross distribution

OMB No. 1545-0119

Profit-Sharing,

$ ‘
Retirement Plans,
2 Taxable amount 1 9) 88 Individual Retirement
$ Arrangements,
Statement for Insurance

PAYER'S Federal identification number | RECIPIENT'S identification number

capital gain election

$

3 Amount in Box 2 eligible for

Recipients of Contracts, Etc.

4 Federal income tax withheld

$

Street address

$

RECIPIENT'S name (first, middle, last) 5 Employee contributions or | 6 Net unrealized appreciation Copy 2
insurance premiums in employer's securities To be filed
with

$

7 Category of distribution

recipient's
state income
tax return,

City, state, and ZIP code 8 Other 9 Your percentage when
$ %|__ distribution % required.

‘Account number (optional)

[10 State income tax withheld

$

1 Payer's state number

Form 1099-R

Department of the Treasury - Internal Revenue Service

(J CORRECTED (if checked)

PAYER'S name, street address, city, state, and ZIP code

1 Gross distribution

Total Distributions From
Profit-Sharing,

OMB No. 1545-0119

$ "
Retirement Plans,
2 Taxable amount 1988 Individual Retirement
$ Arrangements,
Statement for Insurance

PAYER’S Federal identification number | RECIPIENT'S identification number

capital gain election

$

3 Amount in Box 2 eligible for

Recipients of Contracts, Etc.

4 Federal income tax withheld

$

Street address

RECIPIENT'S name (frst, middle, last) 5 Employee contributions or | 6 Net unrealized appreciation Copy 2
insurance premiums in employer's securities To be filed
with
$ $ Fara
recipient's

7 Category of distribution

state income
tax return,

City, state, and ZIP code 8 Other 9 Your percentage
of total when
$ %|_distribution % required.

‘Account number (optional)

[10 State income tax withheld

$

1 Payer's state number

Form 1099-R

Department of the Treasury - Internal Revenue Service




Clvoiw

(J CORRECTED

PAYER'S name, street address, city, state, and ZIP code

1 Gross distribution

‘OMB No. 1545-0119 ]Total Distributions From
Pri

‘Sharing,

$
Retirement Plans,
2 Toxableamount 1988 Individual Retirement
$ Arrangements,
Statement for Insurance

PAYER'S Federal identification number | RECIPIENT'S identification number

capital gain election

$

3 Amount in Box 2 eligible for

Recipients of Contracts, Etc.

44 Federal income tax withheld

$

RECIPIENT'S name (first, middle, last)

Street address

City, state, and ZIP code

5 Employee contributions or
insurance premiums

$

6 Net unrealized appreciation
in employer's securities

$ Copy 1

7 Category of distribution

For State Tax
Department

8 Other

$

9 Your percentage
of total

%|__ distribution

Account number (optional)

[10 State income tax withheld

$

1 Payer’s state number

Form 1099-R

Department of the Treasury - Internal Revenue Service

C1 voip (J CORRECTED
PAYER’S name, street address, city, state, and ZIP code 1 Gross distribution ‘OMB No. 1545-0119 |Total Distributions From
$ Profit Shari ing,
Retirement Plans,
2 Taxable amount 1] 9g 8 8 Individual Retirement
$ Arrangements,
Statement for Insurance

PAYER'S Federal identification number | RECIPIENT'S identification number

capital gain election

$

3 Amount in Box 2 eligible for

Recipients of
4 Federal income tax withheld

$

Contracts, Ete.

RECIPIENT'S name (first, middle, last)

'5 Employee contributions or
insurance premiums

6 Net unrealized appreciation
in employer's securities

$ $ Copy 1
Street address 7 Category of distribution For State Tax
1, Department
City, state, and ZIP code 8 Other 9 Your percentage
of total
$ %| distribution %

‘Account number (optional)

[10 State income tax withheld

$

1 Payer's state number

Form 1099-R

(voip

(-] CORRECTED

Department of the Treasury - Internal Revenue Service

PAYER'S name, street address, city, state, and ZIP code

1 Gross distribution

Total Distributions From
Profit-Sharing,

OMB No. 1545-0119

$ ‘
2 Taableamount Retirement Plans,
q individual Retirement
$ Arrangements,
Statement for Insurance
3 Amount in Box 2 eligible for | Recipients of Contracts, Etc.
PAYER’S Federal identification number | RECIPIENT'S identification number capital gain election 4 Federal income tax withheld
$ $
RECIPIENT'S name (first, middle, last) '5 Employee contributions or | 6 Net unrealized appreciation
insurance premiums in employer's securities
$ $ Copy 1
Street address 7 Category of distribution y For State Tax
Yj 1] Department
City, state, and ZIP code 8 Other ‘9 Your percentage
of total
$ % | distribution %
Account number (optional) 110 State income tax withheld 1 Payer's state number
$

Form 1099-R

Department of the Treasury - Internal Revenue Service