Employee contributions

/Designated Roth

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 Privacy Act

and Paperwork

Reduction Act

Notice, see the

2009 General

Instructions for

Forms 1099,

1098, 3921, 3922,

5498, and W-2G.

$ $

IRA/

SEP/

SIMPLE

Distribution

code(s)

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

%

Your percentage of total

distribution

City, state, and ZIP code 9a

%

1st year of desig. Roth contrib. 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

File with Form 1096.

Cat. No. 14436Q

12

15

State distribution

Local distribution

$

$

$

$

$ $

$

Form 1099-R

9b Total employee contributions

$

Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page

Account number (see instructions)

2009
Employee contributions

/Designated Roth

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 Copy 1

RECIPIENT’S identification

number

PAYER’S federal identification

number

3 Capital gain (included

in box 2a)

4 Federal income tax

withheld

For

State, City,

or Local

Tax Department

$ $

RECIPIENT’S name Net unrealized

appreciation in

employer’s securities

5 6

$ $

IRA/

SEP/

SIMPLE

Distribution

code(s)

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

%

Your percentage of total

distribution

City, state, and ZIP code 9a

%

1st year of desig. Roth contrib. 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

$

$

$

$

$ $

$

Form 1099-R

9b Total employee contributions

$

Account number (see instructions)

2009
This information is

being furnished to

the Internal

Revenue Service.

Employee contributions

/Designated Roth

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 Copy B

RECIPIENT’S identification

number

PAYER’S federal identification

number

3 Capital gain (included

in box 2a)

4 Federal income tax

withheld

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.

$ $

RECIPIENT’S name Net unrealized

appreciation in

employer’s securities

5 6

$ $

IRA/

SEP/

SIMPLE

Distribution

code(s)

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

%

Your percentage of total

distribution

City, state, and ZIP code 9a

%

1st year of desig. Roth contrib. 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

$

$

$

$

$ $

$

Form 1099-R

9b Total employee contributions

$

Account number (see instructions)

2009
Box 1. Shows the total amount you received this year. The

amount may have been a direct rollover, a transfer or conversion

to a Roth IRA, a recharacterized IRA contribution; or you may

have received it as periodic payments, as nonperiodic payments,

or as a total distribution. Report the amount on Form 1040 or

1040A on the line for “IRA distributions” or “Pensions and

annuities” (or the line for “Taxable amount”), and on Form 8606,

as applicable. However, if this is a lump-sum distribution, see

Form 4972. If you have not reached minimum retirement age,

report your disability payments on the line for “Wages, salaries,

tips, etc.” on your tax return. Also report on that line permissible

withdrawals from eligible automatic contribution arrangements

and corrective distributions of excess deferrals, excess

contributions, or excess aggregate contributions except if you

are self-employed.

If a life insurance, annuity, or endowment contract was

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

IRAs. For distributions from a traditional 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. See the

Form 1040 or 1040A instructions to determine the taxable

amount. If you are at least age 701⁄2 , you must take minimum

distributions from your IRA (other than a Roth IRA). If you do not,

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

should have been distributed. See Pub. 590 for more information

on IRAs.

(Continued on the back of Copy C.)

Loans treated as distributions. If you borrow money from a

qualified plan, section 403(b) plan, 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.

Qualified plans. If your annuity starting date is after 1997, you

must use the simplified method to figure your taxable amount if

your payer did not show the taxable amount in box 2a. See 

the instructions for Form 1040 or 1040A.

Roth IRAs. For distributions from a Roth IRA, generally the

payer is not required to compute the taxable amount. You must

compute any taxable amount on Form 8606. An amount shown

in box 2a may be taxable earnings on an excess contribution.

Account number. May show an account or other unique

number the payer assigned to distinguish your account.

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 checked. You may want to get one of the free

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

See Additional information on the back of Copy 2. For an IRA

distribution, see IRAs and Roth IRAs above. For a direct rollover,

other than from a qualified plan to a Roth IRA, zero should be

shown, and you must enter zero (-0-) on the “Taxable amount”

line of your tax return. If you roll over a distribution (other than a

designated Roth account contribution) from a qualified plan

(including a governmental section 457(b) plan) or section 403(b)

plan to a Roth IRA, you must include on the “Taxable amount”

line of your tax return the amount shown in this box plus the

amount in box 6, if any.

What’s new. If any of the distribution relates to your economic

stimulus payment, see the instructions for Form 1040 or 1040A.

Generally, distributions from pensions, annuities, profit-sharing

and retirement plans (including section 457 state and local

government plans), IRAs, insurance contracts, etc., are reported

to recipients on Form 1099-R.
This information is

being furnished to

the Internal

Revenue Service.

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 Copy C

RECIPIENT’S identification

number

PAYER’S federal identification

number

3 Capital gain (included

in box 2a)

4 Federal income tax

withheld

For Recipient’s

Records

$ $

RECIPIENT’S name Net unrealized

appreciation in

employer’s securities

5 6

$ $

IRA/

SEP/

SIMPLE

Distribution

code(s)

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

%

Your percentage of total

distribution

City, state, and ZIP code 9a

%

1st year of desig. Roth contrib. 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

$

$

$

$

$ $

$

Form 1099-R

9b Total employee contributions

$

Account number (see instructions)

(keep for your records)

Employee contributions

/Designated Roth

contributions or

insurance premiums

2009
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.

However, if the distribution was a qualified rollover contribution to a

Roth IRA, see the instructions for Box 2a. See Pub. 575 and the

Form 4972 instructions. 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 following codes identify the distribution you received. For

more information on these distributions, see the instructions for your

tax return. Also, certain distributions may be subject to an additional

10% tax. See the instructions for Forms 5329 and 8606.

Instructions for Recipient ( Continued)

(Continued on the back of Copy 2.)

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

and were born before January 2, 1936 (or you are the beneficiary of

someone born before January 2, 1936), you may be able to elect to

treat this amount as a capital gain on Form 4972 (not on Schedule D

(Form 1040)). See the Form 4972 instructions. For a charitable gift

annuity, report as a long-term capital gain on Schedule D.

Box 4. Shows federal income tax withheld. Include this amount 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.

Box 5. Generally, this shows the employee’s investment in the

contract (after-tax contributions), if any, recovered tax free this year;

the portion that is your basis in a designated Roth account; 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 IRA contributions. If the amount shown

is your basis in a designated Roth account, the year you first made

contributions to that account may be entered in the box next to 

box 10.

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

born before January 2, 1936 (or you are the beneficiary of someone

born before January 2, 1936), you may be eligible for the 10-year tax

option. See the Form 4972 instructions for more information.

Box 2b. If the first box is checked, the payer was unable to

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

second box is checked, the distribution was a total distribution that

closed out your account. If you are an eligible retired public safety

officer who elected to exclude from income distributions from your

eligible plan used to purchase certain insurance premiums, the

amount shown in box 2a has not been reduced by the exclusion

amount. See the instructions for Form 1040 or Form 1040A for more

information.

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

591⁄2).

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

3—Disability.

4—Death.

5—Prohibited transaction.

6—Section 1035 exchange (a tax-free exchange of life insurance,

annuity, or endowment contracts).

7—Normal distribution.

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

earnings) taxable in 2009.

9—Cost of current life insurance protection.

A—May be eligible for 10-year tax option (see Form 4972).

B—Designated Roth account distribution.

D—Excess contributions plus earnings/excess deferrals taxable in

2007.
Employee contributions

/Designated Roth

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 Copy 2

RECIPIENT’S identification

number

PAYER’S federal identification

number

3 Capital gain (included

in box 2a)

4 Federal income tax

withheld

File this copy

with your state,

city, or local

income tax

return, when

required. $ $

RECIPIENT’S name Net unrealized

appreciation in

employer’s securities

5 6

$ $

IRA/

SEP/

SIMPLE

Distribution

code(s)

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

%

Your percentage of total

distribution

City, state, and ZIP code 9a

%

1st year of desig. Roth contrib. 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

$

$

$

$

$ $

$

Form 1099-R

9b Total employee contributions

$

Account number (see instructions)

2009
Box 9a. If a total distribution was made to more than one

person, the percentage you received is shown.

Boxes 10–15. If state or local income tax was withheld from the

distribution, boxes 12 and 15 may show the part of the

distribution subject to state and/or local tax.

Box 9b. For a life annuity from a qualified plan or from a section

403(b) plan (with after-tax contributions), an amount may be

shown for the employee’s total investment in the contract. It is

used to compute the taxable part of the distribution. See 

Pub. 575.

Form 4972, Tax on Lump-Sum Distributions,

Form 5329, Additional Taxes on Qualified Plans (Including IRAs)

and Other Tax-Favored Accounts,

Form 8606, Nondeductible IRAs,

Pub. 560, Retirement Plans for Small Business (SEP, SIMPLE,

and Qualified Plans),

Pub. 571, Tax-Sheltered Annuity Plans (403(b) Plans),

Pub. 575, Pension and Annuity Income,

Pub. 590, Individual Retirement Arrangements (IRAs),

Pub. 721, Tax Guide to U.S. Civil Service Retirement Benefits,

Pub. 939, General Rule for Pensions and Annuities,

Additional information. You may want to see:

If the IRA/SEP/SIMPLE box is checked, you have received a

traditional IRA, SEP, or SIMPLE distribution.

Instructions for Recipient (Continued)

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 use the 10-year tax option (Form 4972).

E—Excess annual additions under section 415 and certain

excess amounts under section 403(b) plans.

F—Charitable gift annuity.

G—Direct rollover of a distribution (other than a designated Roth

account distribution) to a qualified plan, a section 403(b)

plan, a governmental section 457(b) plan, or an IRA.

J—Early distribution from a Roth IRA, no known exception (in

most cases, under age 591⁄2).

L—Loans treated as distributions.

N—Recharacterized IRA contribution made for 2009 and

recharacterized in 2009.

P—Excess contributions plus earnings/excess deferrals taxable

in 2008.

Q—Qualified distribution from a Roth IRA.

R—Recharacterized IRA contribution made for 2008 and

recharacterized in 2009.

S—Early distribution from a SIMPLE IRA in first 2 years, no

known exception (under age 591⁄2).

T—Roth IRA distribution, exception applies.

Pub. 969, Health Savings Accounts and Other Tax-Favored

Health Plans.

H—Direct rollover of a designated Roth account distribution to a

Roth IRA.

Form W-4P, Withholding Certificate for Pension or Annuity

Payments,

U—Dividend distribution from ESOP under sec. 404(k).

Note. This distribution is not eligible for rollover.
Employee contributions

/Designated Roth

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 Copy D

RECIPIENT’S identification

number

PAYER’S federal identification

number

3 Capital gain (included

in box 2a)

4 Federal income tax

withheld

For Payer

$ $

RECIPIENT’S name Net unrealized

appreciation in

employer’s securities

5 6

$ $

IRA/

SEP/

SIMPLE

Distribution

code(s)

Street address (including apt. no.) Other 7

%

Your percentage of total

distribution

City, state, and ZIP code 9a

%

1st year of desig. Roth contrib. 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

$

$

$

$

$ $

$

Form 1099-R

9b Total employee contributions

$

Account number (see instructions)

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2009 General

Instructions for

Forms 1099,

1098, 3921, 3922,

5498, and W-2G.

8

2009
Instructions for Payers

Due dates. Furnish Copies B, C, and 2 of

this form to the recipient by February 1, 2010.

File Copy A of this form with the IRS by

March 1, 2010. If you file electronically, the

due date is March 31, 2010. To file

electronically, you must have software that

generates a file according to the

specifications in Pub. 1220, Specifications for

Filing Forms 1098, 1099, 3921, 3922, 5498,

and W-2G Electronically. IRS does not

provide a fill-in form option.

Printed on recycled paper

Caution: Because paper forms are scanned

during processing, you cannot file with the

IRS Forms 1096, 1098, 1099, 3921, 3922, or

5498 that you print from the IRS website.

We provide general and specific form

instructions as separate products. The

products you should use to complete Form

1099-R are the 2009 General Instructions for

Forms 1099, 1098, 3921, 3922, 5498, and

W-2G and the 2009 Instructions for Forms

1099-R and 5498. A chart in the general

instructions gives a quick guide to which form

must be filed to report a particular payment.

To order these instructions and additional

forms, visit the IRS website at www.irs.gov or

call 1-800-TAX-FORM (1-800-829-3676).

Need help? If you have questions about

reporting on Form 1099-R, call the

information reporting customer service site

toll free at 1-866-455-7438 or 304-263-8700

(not toll free). For TTY/TDD equipment, call

304-267-3367 (not toll free).