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

Statement for

Recipients of 1977
Lump-Sum
Distributions

from Profit-Sharing
and Retirement Plans

Copy C
For Payer’s Record

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

t's. identifying number 2 Capital gain (For lump-sum | 3 Ordinary income

distributions only)

4 Premiums paid by trust for
current life insurance

Type or print Recipient's name, address, and ZIP code below. '5 Employee contributions

6 Life insurance element

7 Net unrealized appreciation in employer's

securities

& Other:

$ | %

‘9 Your percentage of lump-sum distribution pe

rs

This is [| or is not [] a lump-sum distribution.

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

25-11 18272

Form LO99R

Ye GPO : 19%8—0-218-099

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

Department of the Treasury—Internal Revenue Service

Statement for

Recipients of 1977
Lump-Sum
Distributions

from Profit-Sharing
and Retirement Plans

Copy C
For Payer’s Record

t's identifying number 2 Capital gain (For lump-sum

distributions oniy)

1 Amount inclydibi ag income 3 Ordinary income

(Add boxes 2, 3, and

4 Premiums paid by trust for
current life insurance

‘Type or print Recipient's name, address, and ZIP code below. 5 Employee contributions

6 Life insurance element

7 Net unrealized appreciation inemployer’s | 8 Other:
securities $ | %
9 Your percentage of lump-sum distribution pe %

This is [-] or is not [] a lump-sum distribution.
Death benefit exclusion does [| or does not [ ] apply.

Form 1099R Ye GPO: 19%—O-218-099as-1118272

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

Department of the Treasury—Internal Revenue Service

Statement for
Recipients of

Lump-Sum
Distributions

from Profit-Sharing
and Retirement Plans
Copy C

For Payer’s Record

Recipient's identifying number gain (For lump-sum

utions only)

3 Ordinary income

Kes 2,

1 Amount includible as income
(Add bo: 4)

4 Premiums paid by trust for
current life insurance

Type or print Recipient's name, address, and ZIP code below. '5 Employee contributions

6 Life insurance element

7 Net unrealized appreciation in employer's 8 Other:
securities $ | %
@ Your percentage of lamp sum Gilribation be %

This is |] or is not [|] a lump-sum distribution.
Death benefit exclusion does ["] or does not [] apply.

Form 1099R

de GPO : 1980-21099 25-1118272 Department-cf the Treasury—Internal Revenue Service


Notice to Recipients:

(References are to the Internal Revenue Code.)

Lump-Sum_ Distribution—Generally the _ term
“lump-sum distribution” means the distribution or
payment, from a “qualified plan,” within one taxable
year of the recipient, of the balance to the credit
of an employee which becomes payable to the re-
cipient (a) on account of the employee's death, (b)
after the employee attains age 59/2, (c) on account
of the employee's separation from the service, or
(d) after the employee has become 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
treatment. Also, the special 10-year averaging
method does not apply. In such case, report the total
amount of the distribution on Form 1040 under
Miscellaneous Income as “Retirement or profit-
sharing plan distribution(s).”

For additional information, see Publication 575.

Box 2.—This portion of the lump-sum distribu-
tion qualifies for capital gsn treatment. Report this
amount on Schedule D (Form 1040 or Form
and identify it as “Lump-Sum Distributiot See
instruction for death benefit exclusion below. Also

Notice to Recipients:

(References are to the Internal Revenue Code.)

Lump-Sum_ Distribution—Generally the term
“lump-sum distribution” means the distribution or
payment, from a “qualified plan,” within one taxable
year of the recipient, of the balance to the credit
of an employee which becomes payable to the re-
cipient (a) on account of the employee's death, (b)
after the employee attains age 591, (c) on account
of the employee's separation from the service, or
(d) after the employee has become 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
treatment. Also, the special 10-year averaging
method does not apply. In such case, report the total
amount of the distribution on Form 1040 under
Miscellaneous Income as “Retirement or profit-
sharing plan distribution(s).""

For additional information, see Publication 575.

Box 2.—This portion of the lump-sum distribu-
tion qualifies for capital gain treatment. Report this
amount on Schedule D (Form 1040 or Form 1041)
and identify it as “Lump-Sum Distribution.” See
instruction for death benefit exclusion below. Also

Notice to Recipients:

(References are to the Internal Revenue Code.)

Lump-Sum Distribution.—Generally the term
“lump-sum distribution” means the distribution or
payment, from a “qualified plan,” within one taxable
year of the recipient, of the balance to the credit
of an employee which becomes payable to the re-
cipient (a) on account of the employee's death, (b)
after the employee attains age 59¥, (c) on account
of the employee's separation from the service, or
(@) after the employee has become 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
treatment. Also, the special 10-year averaging
method does not apply. In such case, report the total
amount of the distribution on Form 1040 under
Miscellaneous Income as “Retirement or profit-
sharing plan distribution(s).”

For additional information, see Publication 575.

Box 2.—This portion of the lump-sum distribu-
tion qualifies for capital gain treatment. Report this
amount on Schedule D (Form 1040 or Form 1041)
and identify it as “Lump-Sum Distribution.” See
instruction for death benefit exclusion 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 lump-sum distribu-
tion 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 bene-
fit exclusion below.

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

Box 4,—Report this amount on Form 1040 under
Miscellaneous Income as “Premiums paid by trust
for current life insurance.””

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

Box 6—If you are the beneficiary of a deceased
employee, the portion of the distribution which
represents life insurance proceeds to the extent it
exceeds the cash value of the insurance contract is
not taxable.

Box 7.—If the distribution consists in part of
securities of your employer's corporation, the net
unrealized appreciation in these securities is tax
deferred until you sell the securities.

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 lump-sum distribu-
tion 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 bene-
fit exclusion below.

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

Box 4.—Report this amount on Form 1040 under
Miscellaneous Income as “Premiums paid by trust
for current life insurance.”

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

Box 6.—If you are the beneficiary of a deceased
employee, the portion of the distribution which
represents life insurance proceeds to the extent it
exceeds the cash value of the insurance contract is
not taxable.

Box 7.—If the distribution consists in part of
securities of your employer's corporation, the net
unrealized appreciation in these securities is tax
deferred until you sell the securities.

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 lump-sum distribu-
tion 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 bene-
fit exclusion below.

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

Box 4.—Report this amount on Form 1040 under
Miscellaneous Income as “Premiums paid by trust
for current life insurance.”

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

Box 6.—If you are the beneficiary of a deceased
employee, the portion of the distribution which
tepresents life insurance proceeds to the extent it
exceeds the cash value of the insurance contract is
not taxable.

Box 7.—If the distribution consists in part of
securities of your employer's corporation, the net
unrealized appreciation in these securities is tax
deferred until you sell the securities.

Annuity.—If you receive an annuity contract as
part of a lump-sum 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 lump-sum
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 8. You
will need that information if you elect the special
10-year averaging method on Form 5544,

Death Benefit Exclusion.—If you receive a retire-
ment (or profit-sharing) plan distribution as the
beneficiary of a deceased employee (or deceased
disability retiree who died prior to attaining retire-
ment age) you may be entitled to a “death benefit
exclusion” of up to $5,000.

Taxable amounts shown in boxes 2 and 3 for
retirement and profit-sharing plan distributions are
without regard to this exclusion. Allocate the ex-
clusion between capital gain and ordinary income
and include the reduced amounts on your tax
return,

Box 9.—If the lump-sum distribution is made to
more than one person, the percentage you received
is shown in box 9. Enter the percentage on line 1,
Form 5544, Multiple Recipient Special 10-Year Aver-
aging Method, if elected.

Annuity.—If you receive an annuity contract as
part of a lump-sum 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 lump-sum
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 8. You
will need that information if you elect the special
10-year averaging method on Form 5544.

Death Benefit Exclusion.—If you receive a retire-
ment (or profit-sharing) plan distribution as the
beneficiary of a deceased employee (or deceased
disability retiree who died prior to attaining retire-
ment age) you may be entitled to a “death benefit
exclusion” of up to $5,000.

Taxable amounts shown in boxes 2 and 3 for
retirement and profit-sharing plan distributions are
without regard to this exclusion. Allocate the ex-
clusion between capital gain and ordinary income
and include the reduced amounts on your tax
return.

Box 9.—If the lump-sum distribution is made to
more than one person, the percentage you received
is shown in box 9. Enter the percentage on line 1,
Form 5544, Multiple Recipient Special 10-Year Aver-
aging Method, if elected.

Annuity.—If you receive an annuity contract as
part of a lump-sum 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 lump-sum
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 8. You
will need that information if you elect the special
10-year averaging method on Form 5544.

Death Benefit Exclusion.—If you receive a retire-
ment (or profit-sharing) plan distribution as the
beneficiary of a deceased employee (or deceased
disability retiree who died prior to attaining retire-
ment age) you may be entitled to a “death benefit
exclusion” of up to $5,000.

Taxable amounts shown in boxes 2 and 3 for
retirement and profit-sharing plan distributions are
without regard to this exclusion. Allocate the ex-
clusion between capital gain and ordinary income
and include the reduced amounts on your tax
return.

Box 9.—If the lump-sum distribution is made to
more than one person, the percentage you received
is shown in box 9. Enter the percentage on line 1,
Form 5544, Multiple Recipient Special 10-Year Aver-
aging Method, if elected.


/
| Statement for
For Official Use Only Recipients of

Type or print | Lump-Sum

PAYERS Distributions

, address, . .

ZIP code, and | from _Profit-Sharing
Federal and Retirement Plans
identifying Copy A For Internal
number Revenue Service Center

—|

Recipient's identifying wumber J 1 Amount includible as income J 2 Copital gain (For lump-sum [| 3 Ordinary income 4 Promiums paid by trust for
(Add Boxes 2, 3, and 4) distributions only) current ie insurance
98]
Type or print Recipient's name, address, and ZIP code below. (Name [J 5 Employee contributions 6 Life insurance element
must aline with arrow)
Name >

7 Net unrealized appreciation in employer's | 8 Other:
securities |

$

9 Your percentage of lump sum éistribution pe %
This is {_] or iS not [_] @ lump-sum distribution.
Death benefit exclusion does [-] or does not [_] apply.

Form 1099R ‘See Form W-3 for instructions. Department of the Treasury—Internal Revenue Service

| Statement for
For Official Use Only Recipients of

Type or print | Lump-Sum

PAE Distributions

name, address, 4 .

Zip cede, and | from Profit-Sharing
Federal and Retirement Plans
identifying Copy A For Internal
number Revenue Service Center

Recipient's identifying number 1 Amount includible as income 2 Capital gain (For lump-sum ff 3 Ordinary income 4 Premiums paid by trust for
(Add boxes 2, 3, and 4) distributions only) current life insurance
98
Type or print Recipient's name, address, and ZIP code below. (Name [J 5 Employee contributions 6 Life insurance element
must aline with arrow)
Name >
7 Wet unrealized appreciation in employer's | @ Others
securities
$ | 4
9 Your percentage of lump sum distribution pe %
This is [] or is not { ] a lump-sum distribution.
“Death benefit exclusion does [_] or does not [] apply.
Form 1099R ‘See Form W-3 for instructions. Department of the Treasury—Internal Revenue Service
| Statement for
For Official Use Only Recipients of
Type or print | Lump-Sum
PAYERS Distributions
me, address, 5 .
Zip code, and | from Profit-Sharing
Federal and Retirement Plans
identifying Copy A For Internal
number Revenue Service Center
Recipient's identifying number 1 Amount includible as income 2 Capital gain (For lump-sum J 3 Ordinary income 4 Premiums paid by trust for
(Add boxes 2, 3, and 4) distributions only) current life insurance
8
Type or print Recipient's name, address, and ZIP code below. (Name [Jf 5 Employee contributions 6 Life insurance element
must aline with arrow)
Name >

7 Net unrealized appreciation in employer's fF 8 Other:
securities |

$

9 Your percentage of lump-sum distribution pe %
This is [] or is not [|] a lump-sum distribution.
Death benefit exclusion does [-] or does not [_] apply.

Form LO99R See Form W-3 for instructions. Department of the Treasury—Internal Revenue Service




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

Statement for
Recipients of

Lump-Sum
Distributions

from Profit-Sharing
and Retirement Plans

Copy B
For Recipient

Recipient's identifying number 2 Capital gain (For lump-sum

3 Ordinary income
distributions only)

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

4 Premiums paid by trust for
current life insurance

‘Type or print Recipient's name, address, and ZIP code below. 5 Employee contributions

6 Life insurance element

7 Net unrealized appreciation in employer's

securities

8 Other:

$ lL 4

9 Your percentage of lump-sum distribution pe» %

This is [] or is not [] a lump-sum distribution.

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

Form 1099R

This information is being furnished to the Internal Revenue Service.

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

Department of the Treasury—Internal Revenue Service

Statement for
Recipients of

Lump-Sum
Distributions

from Profit-Sharing
and Retirement Plans

Copy B
For Recipient

Recipient's Identifying number | 1 Amount includible as income | 2 Capital gain (For lump-sum | 3 Ordinary income
(Add boxes 2, 3, and 4) distributions only)

4 Promiums paid by trust for
current life insurance

Type or print Recipient's name, address, and ZIP code below. '5 Employee contributions

6 Life insurance element

7 Not unrealized appreciation in employer's

securities

8 Other:

$ | 4

9 Your percentage of lump sum distribution pe %

This is |] or is not [] @ lump-sum distribution.

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

Form 1099R

This information is being furnished to the Internal Revenue Service.

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

Department of the Treasury—Internal Revenue Service

Statement for
Recipients of

Lump-Sum
Distributions

from Profit-Sharing
and Retirement Plans

Copy B
For Recipient

1 Amount includible as. income

Reciptont’s. identifying number gain (For lump-sum
(Add boxes 2, 3, and 4)

2 Cat 3 Ordinary income
distributions only)

4 Premiums paid by trust for
current life insurance

Type or print Recipient's name, address, and ZIP code below. '5 Employee contributions

element

7 Net unrealized appreciation inemployer’s | 8 Other:
securities 3 | %
9 Your percentage of lump-sum distribution pp» %

This is |] or is not |] a lump-sum distribution.

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

Form 1099R

‘This information is being furnished to the Internal Revenue Service.

Department of the Treasury—Internal Revenue Service