Employee contributions

or insurance premiums

9 8 9 8 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 Amount in Box 2a

eligible for capital

gain election

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

%

State/Payer’s state

number

State income tax 11

withheld

Account number (optional) 10

$

12 Local income tax

withheld

13 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

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 Amount in Box 2a

eligible for capital

gain election

4 Federal income tax

withheld

$ $

RECIPIENT’S name Net unrealized

appreciation in

employer’s securities

Employee contributions 6

or insurance premiums

5

$ $

IRA/

SEP

Distribution

code

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

%

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

%

State/Payer’s state

number

State income tax 11

withheld

Account number (optional) 10

$

12 Local income tax

withheld

13 Name of locality

$

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

Copy 1

For

State, City,

or Local

Tax Department

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 Amount in Box 2a

eligible for capital

gain election

4 Federal income tax

withheld

$ $

RECIPIENT’S name Net unrealized

appreciation in

employer’s securities

Employee contributions 6

or insurance premiums

5

$ $

IRA/

SEP

Distribution

code

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

%

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

%

State/Payer’s state

number

State income tax 11

withheld

Account number (optional) 10

$

12 Local income tax

withheld

13 Name of locality

$

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

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 received as periodic payments, as

nonperiodic payments, or as a total distribution. Report this

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, an amount will be shown in this box and Code 6 will be

shown in Box 7.

Instructions to Recipient

Generally, distributions from pensions, annuities, profit-sharing

and retirement plans, IRAs, insurance contracts, etc., are

reported to recipients on Form 1099-R. Some distributions may

be reported on Form W-2, Wage and Tax Statement.

Eligible Rollover Distribution.—If you received a distribution

that is eligible to be rolled over, the plan administrator is

required to give you an explanation of the rollover provisions of

the law and, if applicable, the 5- or 10-year averaging provisions.

Each of these provisions could affect the amount of tax you pay

on this distribution. For example, any amount you roll over is not

currently taxable. See Pub. 575, Pension and Annuity Income

(Including Simplified General Rule), 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 2a may be the

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

and Form 8606, Nondeductible IRA Contributions, IRA Basis,

and Nontaxable IRA Distributions, to determine the taxable

amount.

Excess Distributions.—If the distribution you received is more

than $136,204, you may owe an excise tax. See Form 5329,

Return for Additional Taxes Attributable to Qualified Retirement

Plans (Including IRAs), Annuities, and Modified Endowment

Contracts. The tax on excess distributions does not apply to

beneficiaries unless you are a surviving spouse and 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 checked. 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.

If this is a total distribution, 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.

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.”
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 Amount in Box 2a

eligible for capital

gain election

4 Federal income tax

withheld

$ $

RECIPIENT’S name Net unrealized

appreciation in

employer’s securities

Employee contributions 6

or insurance premiums

5

$ $

IRA/

SEP

Distribution

code

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

%

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

%

State/Payer’s state

number

State income tax 11

withheld

Account number (optional) 10

$

12 Local income tax

withheld

13 Name of locality

$

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

Copy C

For Recipient’s

Records

This information

is being furnished

to the Internal

Revenue Service.

Keep this copy

for your records.
1—Early (premature) distribution, no known exception (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 (premature) distribution exception applies (You need not

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

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

transactions; 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 1992; 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 1991; A—Qualifies for 5- or 10-year

averaging; B—Qualifies for death benefit exclusion; C—Qualifies

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

deferrals taxable in 1990.

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

SEP distribution.

Box 8.—If you receive an annuity contract as part of a

distribution, the value of the contract is shown in this box. 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 in this box. 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, 11, 12, and 13.—If state or local income tax was

withheld from the distribution, these boxes may be completed.

Box 2b.—If an “X” is entered in the first checkbox, the payer

was unable to determine the taxable amount, and Box 2a should

be blank unless this is an IRA distribution. If an “X” is entered in

the second checkbox, the distribution was a total distribution

that closed out your account.

Box 3.—If you received a lump-sum distribution, you may be

able to elect to treat this amount as a capital gain. See the

instructions for Schedule D (Form 1040).

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. If you will receive payments next

year and you want to increase or decrease your withholding or

you want to elect not to have income tax withheld, you must

submit to the payer a new Form W-4P, Withholding Certificate

for Pension or Annuity Payments.

Box 5.—Shows the investment in the contract (cost). This is an

amount contributed or considered contributed by the individual

that was required to be included in the individual’s income when

the contribution was made. It is used to compute the taxable

amount of the distribution. 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 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 for more information. 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.—The code(s) listed identifies the distribution you

received:

Instructions to Recipient (Continued from the back of

Copy B.)
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 Amount in Box 2a

eligible for capital

gain election

4 Federal income tax

withheld

$ $

RECIPIENT’S name Net unrealized

appreciation in

employer’s securities

Employee contributions 6

or insurance premiums

5

$ $

IRA/

SEP

Distribution

code

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

%

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

%

State/Payer’s state

number

State income tax 11

withheld

Account number (optional) 10

$

12 Local income tax

withheld

13 Name of locality

$

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

Copy 2

File this copy

with your

state, city, or

local income

tax return,

when required.

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 Amount in Box 2a

eligible for capital

gain election

4 Federal income tax

withheld

$ $

RECIPIENT’S name Net unrealized

appreciation in

employer’s securities

Employee contributions 6

or insurance premiums

5

$ $

IRA/

SEP

Distribution

code

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

%

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

%

State/Payer’s state

number

State income tax 11

withheld

Account number (optional) 10

$

12 Local income tax

withheld

13 Name of locality

$

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

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.