Form 1099-R - Record 3 - 2016
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IT-1099-R
Department of Taxation and Finance
Summary of Federal Form 1099-R Statements
New York State • New York City • Yonkers
Do not detach or separate the 1099-R Records below. File Form IT-1099-R as an entire page. See instructions on the back.
WARNING: PLEASE USE A DIFFERENT PDF VIEWER
Name(s) as shown on return
Identifying number as shown on return
You tried to open this form in an application that is not compatible with some of the features enabled in this form.
To solve this problem, please use Adobe® Reader. Please follow the instructions below:
1099-R Record 1
Corrected (1099-R
)
Recipient’s identification
1. Save the form (PDF file) in your hard drive and from now on, work on that document. If you need to fill more than one
number for this 1099-R ..................
Box 11 1st year of desig. Roth contrib.
form, make copies and assign a different file name to each form.
Box A Payer’s name and full address
State
Box 12 State tax withheld (for NY State)
N Y
.
2. If you do not have Adobe® Reader on your computer, you can download it at:
00
Box 14 State distribution
Box B Payer’s federal identification number
.
Box 3 Capital gain
00
(included in box 2a)
3. Open the form you just saved with:
NY State
.
00
Box 15 Local tax withheld (NYC or Yonkers)
.
Box 1 Gross distribution
Box 7 Distribution code(s)
00
- Adobe® Reader (version 5 or higher), or
Locality a
.
.
00
00
Locality b
Box 2a Taxable amount
Box 9a Percentage of distribution
Box 16 Locality name
- Adobe® Acrobat (Standard or Professional).
.
00
Locality a
Box 9b Employee contributions
Locality b
Adobe® Reader v11 (2012) or higher will allow you to save the form data and complete the form in different sessions.
.
00
Box 17 Local distribution
Box 2b Taxable amount not determined
.
Box 10 Amount allocable to IRR within 5 years
00
Locality a
.
.
00
00
Total distribution . ......................
Locality b
Box C Account number
Thank you.
Do not detach.
1099-R Record 2
Corrected (1099-R
)
Recipient’s identification
number for this 1099-R ..................
Box 11 1st year of desig. Roth contrib.
Box A Payer’s name and full address
State
Box 12 State tax withheld (for NY State)
.
N Y
00
Box 14 State distribution
Box B Payer’s federal identification number
.
Box 3 Capital gain
00
(included in box 2a)
NY State
.
Box 15 Local tax withheld (NYC or Yonkers)
00
.
Box 1 Gross distribution
Box 7 Distribution code(s)
00
Locality a
.
.
00
00
Locality b
Box 2a Taxable amount
Box 9a Percentage of distribution
Box 16 Locality name
.
00
Locality a
Box 9b Employee contributions
Locality b
.
00
Box 17 Local distribution
Box 2b Taxable amount not determined
.
Box 10 Amount allocable to IRR within 5 years
00
Locality a
.
.
00
00
Total distribution . ......................
Locality b
Box C Account number
099001173094
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