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

Distribution

code

Street address (including apt. no.) 7 8 Other

%

City, state, and ZIP code 9 Your percentage of total distribution

%

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

$

$

$

$

$ $

$

Employee contributions

or insurance premiums

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

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

$ $

IRA/

SEP

Distribution

code

Street address (including apt. no.) 7 8 Other

%

City, state, and ZIP code 9 Your percentage of total distribution

%

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

$

$

$

$

$

$

Employee contributions

or insurance premiums

CORRECTED (if checked)

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

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

$ $

IRA/

SEP

Distribution

code

Street address (including apt. no.) 7 8 Other

%

City, state, and ZIP code 9 Your percentage of total distribution

%

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.

$

$

$

$ $

$
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.

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 Form 1040 on the line for

“Other income.” See Pub. 525, Taxable and Nontaxable Income.

If an insurance contract has been transferred 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.

Eligible Rollover Distribution.—Before distributing an amount

from a qualified plan eligible to be rolled over, the plan

administrator must give you an explanation of your choices of

how the distribution can be paid, including a direct rollover. See

Pub. 575, Pension and Annuity Income (Including Simplified

General Rule), for more information.

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 2a may be the

same. See Pub. 590, Individual Retirement Arrangements (IRAs),

and Form 8606, Nondeductible IRAs (Contributions,

Distributions, and Basis), to determine the taxable amount. If you

are at least age 701⁄2, distributions from your IRA may be

required. See Pub. 590.

Excess Distributions.—If your distribution from a qualified plan

is more than $144,551, you may owe an excise tax. See Form

5329, Additional Taxes Attributable to Qualified Retirement Plans

(Including IRAs), Annuities, and Modified Endowment Contracts.

This does not apply to beneficiaries except a surviving spouse

who elected not to have the estate pay the excess accumulation

tax.

Beneficiaries.—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 Pub. 575.

(Continued on the back of Copy C.)

Box 2a.—This part of the distribution is generally taxable.

However, 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

should be entered on the “Taxable amount” line of your tax

return.

If this is a total distribution and you were born before 1936 (or

you are the beneficiary of someone born before 1936), you may

be eligible for the 5- or 10-year averaging method. See Form

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

apply to IRAs or tax-sheltered annuities.

Total Employee Contributions.—If this is the first year of a life

annuity, you may see “Total employee contributions” on the

form. Use that figure only 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.

Report this amount on Form 1040 or 1040A 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 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 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

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

$ $

IRA/

SEP

Distribution

code

Street address (including apt. no.) 7 8 Other

%

City, state, and ZIP code 9 Your percentage of total distribution

%

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.)

$

$

$ $

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

SEP 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 elect the special 5- or 10-year averaging method.

Box 9.—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 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.

Box 3.—If you received a lump-sum distribution 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, this is the amount of any long-term capital gain.

Box 4.—This is the amount of Federal income tax withheld on

the distribution. 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 (aftertax 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 any

contributions to an IRA or SEP.

Box 6.—If you received a lump-sum distribution 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

elect otherwise. 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 (premature) distribution, no known exception (under age

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

Instructions for Recipient ( Continued)

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

instructions.); 2—Early (premature) 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 insurance contracts);

7—Normal distribution; 8—Excess contributions plus

earnings/excess deferrals (and/or earnings) taxable in 1994;

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 1993; A—Eligible for 5- or 10-year averaging; B—Eligible for

death benefit exclusion; C—Eligible for both A and B;

D—Excess contributions plus earnings/excess deferrals taxable

in 1992; 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.).
Employee contributions

or insurance premiums

CORRECTED (if checked)

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

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

$ $

IRA/

SEP

Distribution

code

Street address (including apt. no.) 7 8 Other

%

City, state, and ZIP code 9 Your percentage of total distribution

%

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.

$

$

$ $

$ $

Employee contributions

or insurance premiums

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

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

$ $

IRA/

SEP

Distribution

code

Street address (including apt. no.) 7 8 Other

%

City, state, and ZIP code 9 Your percentage of total distribution

%

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.

$ $

$ $
Payers, Please Note—

Specific information needed to complete this form and other

forms in the 1099 series is given in the 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

January 31, 1995.

File Copy A of this form with the IRS by February 28,

1995.

Printed on recycled paper