Return for Additional Taxes Attributable to OMB No. 1545-0203

Qualified Retirement Plans (Including IRAs),

Annuities, and Modified Endowment Contracts

Form 5329

Department of the Treasury

Internal Revenue Service

Attachment

Sequence No. 29

(Under Sections 72, 4973, 4974 and 4980A of the Internal Revenue Code)

© Attach to Form 1040. See separate instructions.

Name of individual subject to additional tax. (Enter the name of one individual only. See the instructions for “Joint Returns.”) Your social security number

Address (number and street). (Enter P.O. box no. if mail is not delivered to street address.)

City, town, or post office, state, and ZIP code If this is an Amended

Return, check here ©

Excess Contributions Tax for Individual Retirement Arrangements (Section 4973)

Complete this part if, either in this year or in earlier years, you contributed more to your IRA than is or was allowable and you

have an excess contribution subject to tax.

1

Excess contributions for 1992 (see instructions). Do not include this amount on Form 1040, line

24a or 24b

1

2

2 Earlier year excess contributions not previously eliminated (see

instructions)

3 Contribution credit. (If your actual contribution for 1992 is less than

your maximum allowable contribution, see instructions for line 3;

otherwise, enter -0-.) 3

4a

4a 1992 distributions from your IRA account that are includible in taxable

income

b 1991 tax year excess contributions (if any) withdrawn after the due

date (including extensions) of your 1991 income tax return, and 1990

and earlier tax year excess contributions withdrawn in 1992 4b

c Add lines 3, 4a, and 4b 4c

Adjusted earlier year excess contributions. (Subtract line 4c from line 2. Enter the result, but not

less than zero.)

5

5

6 Total excess contributions (add lines 1 and 5) 6

7 Tax due. (Enter the smaller of 6% of line 6 or 6% of the value of your IRA on the last day of

1992.) Also enter this amount on Form 1040, line 51 7

Tax on Early Distributions (Section 72)

Complete this part if a taxable distribution was made from your qualified retirement plan (including an IRA), modified endowment contract, or annuity

contract before you reached age 591⁄2 . Note: You must enter the amount of the distribution on the appropriate line (or lines) of Form 1040 or Form 4972.

8 Early distributions included in gross income attributable to:

a Qualified retirement plans (including IRAs) 8a

b Annuity contracts 8b

c Modified endowment contracts 8c

d Prohibited transactions 8d

e Pledging of accounts as security 8e

8f f Cost of collectibles

8g g Total distributions (add lines 8a through 8f)

Note: Include this amount on line 16b or 17b of Form 1040 or on the appropriate line of Form 4972

9 Exceptions to distributions subject to additional taxes (see instructions):

a Due to death (does not apply to modified endowment contracts) 9a

b Due to total and permanent disability 9b

c As part of a series of substantially equal lifetime periodic payments 9c

Lines 9d through 9f DO NOT apply to distributions from IRAs,

annuities, or modified endowment contracts.

d Due to separation from service in or after the year of reaching age 55 9d

e Distributions to the extent of deductible medical expenses 9e

9f f Made to an alternate payee under a qualified domestic relations order

9g g Other (specify)

h Total amount excluded from additional tax (add lines 9a through 9g) 9h

10 Amount subject to additional tax (subtract line 9h from 8g) 10

11 Total section 72 tax (multiply line 10 by 10% (.10)). Enter here and on Form 1040, line 51 11

For Paperwork Reduction Act Notice, see page 1 of separate instructions. Form 5329 (1992)Cat. No. 13329Q

Apt. No.

Part I

Part II
Form 5329 (1992) Page 2

Tax on Excess Accumulation in Qualified Retirement Plans (Including IRAs) (Section 4974)

12 Minimum required distribution (see instructions) 12

13 Amount actually distributed to you 13

14 Subtract line 13 from line 12. If line 13 is more than line 12, enter -0- 14

15 Tax due (multiply line 14 by 50% (.50)). Enter here and on Form 1040, line 51 15

Tax on Excess Distributions From Qualified Retirement Plans (Including IRAs) (Section 4980A)

Complete lines 16a through 19c for regular distributions ONLY.

16a Enter the total amount of regular retirement distributions 16a

Enter the applicable threshold amount ($140,276 or $150,000) (see

instructions)

17a

17a

b 1992 recovery of grandfather amount (from Worksheet 1 or 2) 17b

c Enter the greater of line 17a or 17b 17c

18 Excess distributions (subtract line 17c from line 16c). (If less than zero, enter -0-.) 18

19a Tentative tax (multiply line 18 by 15% (.15)) 19a

b Section 72(t) tax offset (see instructions) 19b

c Tax due (subtract line 19b from line 19a). Enter here and on Form 1040, line 51 19c

Complete lines 20a through 23c for lump-sum distributions ONLY.

20a Enter the total amount of your lump-sum distributions 20a

Enter the applicable threshold amount ($701,380 or $750,000) (see

instructions)

21a

21a

b 1992 recovery of grandfather amount (from Worksheet 1 or 2) 21b

c Enter the greater of line 21a or 21b 21c

22 Excess distributions (subtract line 21c from line 20c). (If less than zero, enter -0-.) 22

23a Tentative tax (multiply line 22 by 15% (.15)) 23a

b Section 72(t) tax offset (see instructions) 23b

c Tax due (subtract line 23b from line 23a). Enter here and on Form 1040, line 51 23c

Acceleration Elections (see the instructions for Part IV, Worksheet 1)

1

2

Note: If you checked 2 above, see the instructions on page 6 for making and revoking the election.

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my

knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has

any knowledge.

Please

Sign

Here Your signature (Sign and date only if not attached to your income tax return.) Date

Preparer’s social security no.

(see instructions) Preparer’s Date

signature

Check if self- Paid employed ©

Preparer’s

Use Only

Firm’s name (or yours,

if self-employed) and

address

E.I. No. ©

ZIP code ©

© ©

©

©

If you elected the discretionary method in 1987 or 1988 and wish to make an acceleration election beginning in 1992

under Temp. Regs. section 54.4981A-1T b-12, check here © .

If you previously made an acceleration election and wish to revoke that election, check here © .

Part IV

Part III

b Amount excluded from additional tax (Enter appropriate No. for exception from instructions © )

c Subtract line 16b from line 16a

b

c Subtract line 20b from line 20a

16b

16c

20b

20c

Amount excluded from additional tax (Enter appropriate No. for exception from instructions © )