Form 1099-R - Distributions From Pensions, Annuities, Retirement Or Profit-Sharing Plans, Iras, Insurance Contracts, Etc. - 2016 Page 2

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VOID
CORRECTED
9898
Distributions From
PAYER’S name, street address, city or town, state or province,
1 Gross distribution
OMB No. 1545-0119
country, and ZIP or foreign postal code
Pensions, Annuities,
Retirement or
2016
$
Profit-Sharing
2a Taxable amount
Plans, IRAs,
Insurance
1099-R
Contracts, etc.
$
Form
2b Taxable amount
Total
Copy A
not determined
distribution
For
PAYER’S federal identification
RECIPIENT’S identification
3 Capital gain (included
4
Internal Revenue
Federal income tax
in box 2a)
withheld
number
number
Service Center
File with Form 1096.
$
$
RECIPIENT’S name
5
6 Net unrealized
Employee contributions
For Privacy Act
/Designated Roth
appreciation in
contributions or
employer’s securities
and Paperwork
insurance premiums
Reduction Act
$
$
Notice, see the
2016 General
Street address (including apt. no.)
7 Distribution
IRA/
8 Other
SEP/
Instructions for
code(s)
SIMPLE
Certain
$
%
Information
9b
9a
Total employee contributions
City or town, state or province, country, and ZIP or foreign postal code
Your percentage of total
Returns.
distribution
$
%
10
11 1st year of
12
13 State/Payer’s state no. 14 State distribution
Amount allocable to IRR
FATCA filing
State tax withheld
requirement
within 5 years
desig. Roth contrib.
$
$
$
$
$
Account number (see instructions)
15
16 Name of locality
17 Local distribution
Local tax withheld
$
$
$
$
1099-R
Form
Cat. No. 14436Q
Department of the Treasury - Internal Revenue Service
Do Not Cut or Separate Forms on This Page
—
Do Not Cut or Separate Forms on This Page

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