(CD CORRECTED (i

if checked)

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

1 Gross distribution

‘otal Distributions From
Profit-Sharing,

OMB No. 1545-0119

3 Amount in Box 2 eligible for

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

capital gain election

$

$
Retirement Plans,
2 Texableamount q 98 9 Individual Retirement
$ Arrangements,
Statement for Insurance

Recipients of Contracts, Etc.

4 Federal income tax withheld

Copy B

RECIPIENT'S name (first, middle, last)

5 Employee contributions or
insurance premiums

6 Net unrealized appreciation
in employer's securities

For Recipient

$ $
Street address 7 Category of distribution _ .
This information
City, state, and ZIP cod Soin 9 Y t is being furnished
ty, State, and ZIP code er ‘our percentage
of total 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

(CJ) CORRECTED (if checked)

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

1 Gross distribution

$

2 Taxable amount

PTT
LMM

3 Amount in Box 2 eligible for

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

capital gain election.

$

‘OMB No. 1545-0119 |Total Distributions From
Profit-Sharing,

Retirement Plans,

af 989 Individual Retirement
Arrangements,

Statement for insurance
Recipients of Contracts, Etc.

4 Federal income tax withheld

s Copy B

RECIPIENT'S name (first, middle, last)

'5 Employee contributions or
insurance premiums.

6 Net unrealized appreciation “oP
in employer's securities For Recipient

$ $
Street address 7 Category of distribution a
This information
is being furnished
City, state, and ZIP code 8 Other 9 Your percentage to the Internal
of total n
$ %| distribution %_| Revenue Service

‘Account number (optional)

[10 State mcome 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 ‘OMB No. 1545.0119 |Total Distributions From
$ Profit-Sharing,
Retirement Plans,
2 Taxable amount Y
aanie amon 1989 Individual Retirement
Arrangements,
Statement for Insurance
3 Amount in Box 2eligible for | Recipients of Contracts, Etc.
PAYER’S Federal identification number | RECIPIENT'S identification number capital gain election 4 Federal income tax withheld
$ s Copy B
RECIPIENT'S name (first, middle, last) 5 Employee contributions or | 6 Net unrealized appreciation Py
insurance premiums inemployer's securities For Recipient

$

This information

Street address 7 Category of distribution
City, state, and ZIP code 8 Other 9 Your percentage
of total
$ % | distribution %

is being furnished
to the Internal
Revenue Service.

‘Account number (optional)

lt State income tax withheld

$

1 Payer’s state number

Form 1099-R

Department of the Treasury - Internal Revenue Service






Eligible Rollover Distribution. —if this 1s an eligible rollover distribution, the plan
administrator 1s required to furnish to you an explanation of the rollover provisions of
tthe 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 mare information about these provisions.

IRAs. —For distributions from an individual retirement arrangement (IRA) or simplified
employee pension (SEP), generally the payer 1s not requirea 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 toa “death benefit exclusion” of up to
$5,000. See Publication 575

Excess Distributions.—!t the amount you received is more than $117,529, you may
owe an excise tax. See Form 5329, Return for Individual Retirement Arrangement and
Qualified Retirement Pans Taxes,

Box 1.—The total amount of the distribution. 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 Box 2, and
Code 4 will be shown in Box 7. See Publication 525, Taxable and Nontaxable Income.
Box 2.—This part of the distribution 1s 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.
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 mformation 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 withhek

Eligible Rollover Distribution.—I this 1s an eligible rollover distribution, the plan
administrator is required to furmish 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 determune 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 $117,529, you may
‘owe an excise tax. See Form 5329, Return for Individual Retirement Arrangement and
Qualified Retirement Pians Taxes.

Box 1.—The total amount of the distribution. 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 Box 2, and
Code 4 will be shown in Box 7. See Publication 525, Taxable and Nontaxable Income.
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.
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 mformation about this distribution.

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

Eligible Rollover Distribution. —If this 1s 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 RA Distributions, to determine the taxable
amoun

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.—1f the amount you received ts more than $117,529, you may
‘owe an excise tax. See Form 5329, Return for Individual Retirement Arrangement and
Qualified Retirement Pians Taxes.

Box 1.—The total amount of the distribution. 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 Box 2, and
Code 4 will be shown in Box 7. See Publication 525, Taxable and Nontaxable Income.
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-Sim
Distributions, for more information. 5-year/10-year averaging does not apply to IRAs.
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 or excludable by the individual when the contribution was made (minus
nontaxable amounts previously distributed) are not taxable to the individual when
distributed. This box wii not show any contributions to an IRA or SEP but will show
premiums paid on commercial annuities or msurance contracts.

Box 6.—I* 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 is taxed only when you sell the securities unless you elect otherwise.

Box 7.—No code may be present if the amount in Box 1s 2 norma! distribution from a
plan othe: than an IRA or SEP The code(s) listed identifies the distribution you
received, a5 follows:

1—Premature distribution (other than codes 2, 3, 4, 5, 8, 9, D, 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-—Eycess contributions plus earnings/excess deferrals (and/or earnings) taxable in
1989: 58 costs; P-—Excess contributions plus earnings/excess deferrals
taxable in 1988; A— Qualifies for 5-year/i0-year averaging; B—Qualifies for death

beneiit exclusion; C—Qualifies for both A and B; D—Exess contributions plus
carr.ngs/excess deferrals taxable in 1987,
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 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.
Box 9.——if the total distribution is made to more than one person, the percentage you
received is shown here.

Box 5.—Amounts contributed or considered contributed by the individual that were
not deductible or excludable 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, 9, D, 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 plus earnings/excess deferrals (and/or earnings) taxable in
1989; 9—PS 58 costs; P—-Excess contributions plus earnings/excess deferrals,
taxabie in 1988; A—Qualifies for 5-year/10-year averaging; B—Qualities for death
benefit exclusion; C—Qualifies for both A and B; D—Exess contributions plus
earnings/excess deferrals taxable in 1987.
Box 8.—if you receive an annuity contract as part of a distribution, the value of the
contract 1s not taxable when you recerve 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 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.
Box 9.——If the total distribution is made to more than one person, the percentage you
received 1s shown here

Box 5.—Amounts contributed or considered contributed by the individual that were
not deductible or excludable 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, 9, D, 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 plus earnings /excess deferrals (and/or earnings) taxable in
‘9—PS 58 costs; P—Excess contributions plus earnings/excess deferrals
taxable in 1988; A—Qualifies for 5-year/ 10-year averaging; B—Qualifies for death
benefit exclusion; C—Qualifies for both A and B; D—Exess contributions plus
‘earnings/excess deferrals taxable in 1987.
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 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.
Box 9.—f the total distribution is made to more than one person, the percentage you
received is shown here.



voi

(J) CORRECTED

PAYERS name, street address, city, state, and ZIP code

1 Gross distribution

otal Distributions From
Profit-Sharing,

OMB No. 1545-0119

$

Retirement Plans,
2 Texabieamount | 989 Individual Retirement
$ Arrangements,
YI) Statement for Insurance
3 Amount 1m Box 2 eligible ‘or Recipients of Contracts, Etc.

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

capital gain election

$

4 Federal income tax withheld

$ Copy C

For Payer

RECIPIENT'S name (first, middle, last)

Street address

'5 Employee contributions or
insurance premiums

$

6 Net unrealized appreciation
in employer's secbirities For Paperwork
Reduction Act

Notice and

$

7 Category of distribution

instructions for
corrpleting this
form, see

City, state, and ZIP code 8 Other 9 Your percentage Instructions for
a

$ 96{ distribution % 1098. Berd

‘Account number (aptional) 0 State income tax withheld 1 Payer's state number 10964, and ae.
$

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

Clvoio [[) coRRECTED

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 Toxableamount 1989 Individual Retirement

$ Arrangements,

Wy ig
YE, $staternentt tor Insurance
3 Amount in Box 2eligible for | Recipients of Contracts, Etc.

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

capital gain election.

$

4 Federal income tax withheld

$ Copy C

For Payer

RECIPIENT'S name (first, middle, last)

5 Employee contributions or
insurance premiums

6 Net unrealized appreciation
in employer's securities For Paperwork

Reduction Act

$

$ $ Notice and

Street address. 7 Category of distribution instructions for

completing this

form, see

City, state, and ZIP code @ Other 9 Your percentage Instructions for
of total

$ %| distribution % eos 103

‘Account number (optional) HO State income tax withheld [1.1 Payer’s state number 1096. 098 4 ie

Form 1099-R

voip

(I corRECTED

Department of the Treasury - Internal Revere Service

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

1 Gross distribution

$

Total Distributions From
Profit-Sharing,

OMB No. 1545-0119

2 Taxable amount

3 Amount in Box 2 eligible for

RECIPIENT'S identification number

capital gain election

MMM

Retirement Plans,
Individual Retirement

1989

Arrangements,
Statement for Insurance
Recipients of Contracts, Etc.

4 Federal income tax withheld

PAYER'S Federal identification number

$ $ Copy C
For Payer

RECIPIENT'S name (first, middle, last) 5 Employee contributions or | 6 Net unrealized appreciation
insurance premiums in employer's securities For Paperwork
Reduction Act
$ $ ___ Notice and
Street address 7 Category of distribution instructions for
completing this
form, see
City, state, and ZIP code 8 Other 9 Your percentage Instructions for

of total

$ %| _ distribution % Forms 1099,
1098, 5498,

‘Account number (optional)

l10 State income tax withheld

$

1096, and W-2G.

i Payer's state number

Form 1099-R

Department of the Treasury - Internal Revenue Service


9898 Civoip [|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,
2 Table amount Retirement Plans,
q Individual Retirement
Wy Arrangements,
VT, Staternentt for Insurance
'3 Amount in Box 2eligible for | Recipients of Contracts, Etc.
PAYER'S Federal identification number | RECIPIENT'S identification number capital gain election 4 Federal income tax withheld CopyA
$ $ For Internal
atk sai Revenue
Type or machine print RECIPIENT'S name (first, middle, last) 5 Employee contributions or | 6 Net unrealized appreciation

" ep (frst insurance premiums inemployer's securities Service Center
For Paperwork
$ Reduction Act
- Notice and

Street add 7 Category of distribution . i
a sey instructions for
completing this
City, state, and ZIP code 8 Other 9 Your percentage form, see
Instructions for
§ - ithhold * T dst oe * Forms 1099,
‘Account number (optional) [10 State income tax withhek yer's state number 1098, 5498,
$ 1096, and W-2G.
Form 1099-R Department of the Treasury - internal Revenue Service

Do NOT Cut or Separate Forms on This Page

Fats Civoip [CORRECTED __ ForOfficial 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,
2 Taxableamount Retirement Plans,
1 9 Individual Retirement
— Arrangements,
YW 7], Statement for Insurance
3 Amount in Box 2eligible for | Recipients of Contracts, Etc.
PAYER'S Federal identification number | RECIPIENT'S identification number capital gain election 4 Federal income tax withheld Copy A
t $ $ For Internal
- 5 i Revenue

1 hune print RECIPIENT'S name (first, middle, last '5 Employee contributions or | 6 Net unrealized appreciation
ypecormacnine pn ‘ idole, let) insurance premiums. in employer's securities Service Center

‘or Paperwor!
$ $ Reduction Act
Street address 7 Category of distribution inst tice and
completing this
City, state, and ZIP code @ Other 9 Your percentage form, see
% r

$ %| distribution % Instructions for
‘Account number (optional) I10 State income tax withheld [11 Payer’s state number 1098, 5498,
$ 1096, and W-2G.
Form 1099-R Department of the Treasury - Internal Revenue Service

Do NOT Cut or Separate Forms on This Page

9698 CivoiD [CORRECTED __ForOfficial 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,

2 Taxable amount Retirement Plans,
Individual Retirement

lL — Arrangements,

: TLL, $*2tervent for Insurance

3 Amount in Box 2eligiblefor | Recipients of Contracts, Etc.

: SG SG capital gain election = .

PAYER’S Federal identification number | RECIPIENT'S identification number “4 Federal income tax withheld Copy A
$ $ For Internal

oon ares Revenue

Ts hine print RECIPIENT'S name (first, middle, last '5 Employee contributions or | 6 Net unrealized a

ypeermacnine pt name rst mide ast) insuranee premiums |” inemplayer's secures, Service Center
For Paperwork

$ $ Reduction Act

Street addi 7 Category of distributio . lotice and
reste aceon " instructions for
Ud Ml completing this

City, state, and ZIP code 8 Other 9 Your percentage form, see
$ ol es | haga

‘Account number (optional) lt0 State income taxwithheld fll Payer's state number Foe 8a 5498, ‘3
$ 1096, and W-2G.

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 ‘OMB No. 1545.0119 |Total Distributions From
$ Profit-Sharing,
2 Tanable amount Retirement Plans,
1 9g 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
$ $
RECIPIENT'S name (first, middle, last) 5 Employee contributions or | 6 Net unrealized appreciation Copy 2
imsurance premiums in employer's securities To be filed
$ $ with
Street address 7 Category ofdistribution —-Y recipient's
state income
ci id ZIP cod 8 Oth 9% te a] tax return,
ity, state, and ZIP code ther ‘our 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

(LJ CORRECTED (if checked)

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

1 Gross distribution

$

‘otal Distributions From
Profit-Sharing,

OMB No. 1545-0119

2 Taxable amount

N

3 Amount in Box 2 eligible for

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

capital gain election

$

TLL

Retirement Plans,
Individual Retirement
Arrangements,
Insurance

Contracts, Etc.

1989

Statement for
Recipients of

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, imemployer's securities To be filed

$ $ with

recipient's

7 Category of distribution

yy

state income

tax return,

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

Account number (optional)

(0 State income tax withheld

$

1 Payer's state number

Form 1099-R

(1 CORRECTED (

Department of the Treasury - Internal Revenue Service

if checked)

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

1 Gross distribution

$

2 Taxable amount

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

capital gain election

$

$

3 Amount in Box 2 eligible for

‘OMB No. 1545-0119 [Total Distributions From
Profit-Sharing,

Retirement Plans,

1989 Individual Retirement
Arrangements,

Statement for Insurance
Recipients of Contracts, Etc.

4 Federal income tax withheld

$

$

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

‘ jent’s

Street address 7 Category of distribution 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




Ovo

(1) CORRECTED

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

1 Gross distribution

$

2 Taxable amount.

$

3 Amount in Box 2 eligible for

‘OMB No. 1545-0119 |Total Distributions From
Profit-Sharing,

Retirement Plans,

1] 989 Individual Retirement
Arrangements,

Statement for Insurance
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
insurance premiums

6 Net unrealized appreciation
in employer's securities

$ $ Copy 1
Street address 7 Category of distribution For State Tax
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

Department of the Treasury - internal Revenue Service

Clvoip [CORRECTED

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 H
‘meable amount 1 98 9 Individual Retirement
Arrangements,
[fj 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

3 $

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

Copy1

7 Category of distribution

8 Other

$ %

For State Tax
Department

9 Your percentage
of total

distribution

Account number (optional)

[LO State income tax withheld

$

11 Payer’s state number

Form 1099-R

Department of the Treasury - Internal Revenue Service

Civoip  [_] CORRECTED
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
arabieamou 1 98 9 Individual Retirement
$ — Arrangements,
VILL, 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 For State Tax
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

Department of the Treasury - Internal Revenue Service