Form 1099-R - Distributions From Pensions, Annuities, Retirement - 2013 Page 3
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8
9
10
11VOID
CORRECTED
Distributions From
PAYER’S name, street address, city or town, province or state,
1 Gross distribution
OMB No. 1545-0119
Pensions, Annuities,
country, and ZIP or foreign postal code
Retirement or
2013
$
Profit-Sharing
2a Taxable amount
Plans, IRAs,
Insurance
Contracts, etc.
1099-R
$
Form
2b Taxable amount
Total
Copy 1
not determined
distribution
For
PAYER’S federal identification
RECIPIENT’S identification
3 Capital gain (included
4
Federal income tax
State, City,
in box 2a)
withheld
number
number
or Local
Tax Department
$
$
RECIPIENT’S name
5
6 Net unrealized
Employee contributions
/Designated Roth
appreciation in
contributions or
employer’s securities
insurance premiums
$
$
Street address (including apt. no.)
7 Distribution
IRA/
8 Other
SEP/
code(s)
SIMPLE
$
%
9b
9a
Total employee contributions
City or town, province or state, country, and ZIP or foreign postal code
Your percentage of total
distribution
$
%
10
11
12
13 State/Payer’s state no. 14 State distribution
Amount allocable to IRR
1st year of desig. Roth contrib.
State tax withheld
within 5 years
$
$
$
$
$
Account number (see instructions)
15
16 Name of locality
17 Local distribution
Local tax withheld
$
$
$
$
1099-R
Form
Department of the Treasury - Internal Revenue Service
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