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 Paperwork

Reduction Act

Notice and

instructions for

completing this

form, see

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

Do NOT Cut or Separate Forms on This Page

File with Form 1096.

Cat. No. 14436Q

12

15

State distribution

Local distribution

$

$

$

$

$ $

$

Form 1099-R

9b Total employee contributions

$

97
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

$

97

IRA/

SEP/

SIMPLE
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

$

97

IRA/

SEP/

SIMPLE
Box 1.—Shows the total amount you received this year. The amount

may have been a direct rollover or received as periodic payments, as

nonperiodic payments, or as a total distribution. Report this amount

on your tax return on the line for “Total IRA distributions” or “Total

pensions and annuities” (or the line for “Taxable amount”), whichever

applies, unless this is a lump-sum distribution and you are using

Form 4972, Tax on Lump-Sum Distributions. However, if you have

If you received a death benefit payment made by an employer

because you are the beneficiary of a deceased employee and the

payment was not made from the employer’s pension, profit-sharing,

or retirement plan, report this amount, less any allowable death

benefit exclusion, on your tax return on the line for “Other income.”

See Pub. 525, Taxable and Nontaxable Income.

If a life insurance, annuity, or endowment contract has been

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, IRAs, insurance contracts, etc., are reported to

recipients on Form 1099-R.

IRAs.—For distributions from an 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 Pub. 590, Individual

Retirement Arrangements (IRAs), SEP-IRAs, and SIMPLE IRAs and

Form 8606, Nondeductible IRAs (Contributions, Distributions, and

Basis), to determine the taxable amount. If you are at least age 701⁄2,

you must take minimum distributions from your IRA. If you don’t, you

may be subject to a 50% excise tax on the amount that should have

been distributed. See Pub. 590 and Pub. 560, Retirement Plans for

Small Business.

Beneficiaries.—If you receive a plan distribution as the beneficiary

of an employee who died before August 21, 1996, you may be

entitled to a death benefit exclusion of up to $5,000. See Pub. 575.

(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 marked. You may want to get one of the following

publications from the IRS to help you figure the taxable amount:

Pub. 571, Tax-Sheltered Annuity Programs 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, Pension General Rule (Nonsimplified Method). For an IRA

distribution, see IRAs on this page. For a direct rollover, zero should

be shown, and you must enter zero on the “Taxable amount” line of

your tax return.

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

least age 591⁄2 on the date of distribution (or you are the beneficiary

of someone who had reached age 591⁄2 or someone born before

1936), you may be eligible for the 5- or 10-year tax option. See Form

4972 for more information. The 5- or 10-year tax option does not

apply to IRAs or tax-sheltered annuities.

Box 2b.—If the first checkbox is marked, the payer was unable to

determine the taxable amount, and box 2a should be blank unless

this is an IRA distribution. If the second checkbox is marked, 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

for details.

Qualified Plans.—If your annuity starting date is after November 18,

1996, generally, you must use the simplified general rule to compute

your taxable amount. See Pub. 575, Pension and Annuity Income.

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.
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

$

97

IRA/

SEP/

SIMPLE
If the IRA, SEP, or SIMPLE box is marked, you have received an

IRA, SEP, or SIMPLE IRA 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 choose the special 5- or 10-year

tax option.

Box 9a.—If a total distribution was made to more than one person,

the percentage you received is shown here.

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 applicable state and/or

local tax.

Box 3.—If you received a lump-sum distribution from a qualified plan

and you 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. See the Instructions for Form 4972. For a

charitable gift annuity, any long-term capital gain is shown.

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 contributions to an IRA, SEP, or

SIMPLE.

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.—These codes identify the distribution you received:

1—Early distribution, no known exception (in most cases, under age

591⁄2) (See Form 5329. For a rollover of the entire taxable part of the

distribution, do not file Form 5329. See Form 1040 or 1040A

instructions.); 2—Early distribution exception applies (under age 591⁄2)

(You need not file Form 5329.); 3—Disability (You need not file Form

5329.); 4—Death (You need not file Form 5329.); 5—Prohibited

transaction; 6—Section 1035 exchange (a tax-free exchange of life

insurance, annuity, or endowment contracts); 7—Normal distribution;

Instructions for Recipient ( Continued)

Box 9b.—If this is the first year of a life annuity from a qualified plan

or from a tax-sheltered annuity (with after-tax contributions), the

amount shown is the employee’s total investment in the contract.

Use it if you choose to compute the taxable part of the distribution

using a method different from the method used by the payer. See

Pub. 575.

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

earnings) taxable in 1997; 9—PS 58 costs (premiums paid by a

trustee or custodian for current insurance protection, taxable to you

currently); P—Excess contributions plus earnings/excess deferrals

taxable in 1996; A—May be eligible for 5- or 10-year tax option (See

Form 4972.); B—May be eligible for death benefit exclusion (if

employee died before August 21, 1996); C—May be eligible for both

A and B; D—Excess contributions plus earnings/excess deferrals

taxable in 1995; E—Excess annual additions under section 415

(Report on your tax return on the line for taxable pension or annuity

income. You need not file Form 5329.); F—Charitable gift annuity;

G—Direct rollover to IRA (You need not file Form 5329.); H—Direct

rollover to qualified plan or tax-sheltered annuity. (You need not file

Form 5329.); L—Loans treated as distributions; S—Early distribution

from a SIMPLE IRA in first 2 years, no known exception (under age

591⁄2) (May be subject to a 25% penalty. See 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

$

97

IRA/

SEP/

SIMPLE
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

$

$

For Paperwork

Reduction Act

Notice and

instructions for

completing this

form, see

Instructions for

Forms 1099,

1098, 5498,

and W-2G.

$ $

$ $

OMB No. 1545-0119

Your percentage of total

distribution

9a

%

Form 1099-R

9b Total employee contributions

$

97

IRA/

SEP/

SIMPLE
Payers, Please Note—

Specific information needed to complete this form and

other forms in the 1099 series is given in the 1997

Instructions for Forms 1099, 1098, 5498, and W-2G.

A chart in those instructions gives a quick guide to

which form must be filed to report a particular

payment. You can order those instructions and

additional forms by calling 1-800-TAX-FORM

(1-800-829-3676).

Furnish Copies B and C of this form to the recipient

by February 2, 1998.

File Copy A of this form with the IRS by March 2,

1998.