Form 4972 - Tax On Lump-Sum Distributions - 2015
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44972
Tax on Lump-Sum Distributions
OMB No. 1545-0193
2015
Form
(From Qualified Plans of Participants Born Before January 2, 1936)
Information about Form 4972 and its instructions is available at
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Department of the Treasury
Attachment
28
Attach to Form 1040, Form 1040NR, or Form 1041.
Internal Revenue Service (99)
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Sequence No.
Identifying number
Name of recipient of distribution
Part I
Complete this part to see if you can use Form 4972
Yes No
1
Was this a distribution of a plan participant’s entire balance (excluding deductible voluntary employee
contributions and certain forfeited amounts) from all of an employer’s qualified plans of one kind (for
example, pension, profit-sharing, or stock bonus)? If “No,” do not use this form
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2
Did you roll over any part of the distribution? If “Yes,” do not use this form .
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3
Was this distribution paid to you as a beneficiary of a plan participant who was born before January 2, 1936?
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Were you (a) a plan participant who received this distribution, (b) born before January 2, 1936, and (c) a
participant in the plan for at least 5 years before the year of the distribution?
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4
If you answered “No” to both questions 3 and 4, do not use this form.
5 a Did you use Form 4972 after 1986 for a previous distribution from your own plan? If “Yes,” do not use this
form for a 2015 distribution from your own plan
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5a
b If you are receiving this distribution as a beneficiary of a plan participant who died, did you use Form 4972
for a previous distribution received as a beneficiary of that participant after 1986? If “Yes,” do not use this
form for this distribution .
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5b
Part II
Complete this part to choose the 20% capital gain election
(see instructions)
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6
Capital gain part from Form 1099-R, box 3 .
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7
Multiply line 6 by 20% (.20) .
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If you also choose to use Part III, go to line 8. Otherwise, include the amount from line 7 in the
total on Form 1040, line 44; Form 1040NR, line 42; or Form 1041, Schedule G, line 1b.
Part III
Complete this part to choose the 10-year tax option
(see instructions)
8
If you completed Part II, enter the amount from Form 1099-R, box 2a minus box 3. If you did not
complete Part II, enter the amount from box 2a. Multiple recipients (and recipients who elect to
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include NUA in taxable income) see instructions .
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9
Death benefit exclusion for a beneficiary of a plan participant who died before August 21, 1996
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9
10
Total taxable amount. Subtract line 9 from line 8 .
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11
Current actuarial value of annuity from Form 1099-R, box 8. If none, enter -0-
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12
Adjusted total taxable amount. Add lines 10 and 11. If this amount is $70,000 or more, skip lines
13 through 16, enter this amount on line 17, and go to line 18
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12
13
Multiply line 12 by 50% (.50), but do not enter more than $10,000 .
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14
Subtract $20,000 from line 12. If line 12 is
$20,000 or less, enter -0-
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14
15
Multiply line 14 by 20% (.20)
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15
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16
Minimum distribution allowance. Subtract line 15 from line 13
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17
Subtract line 16 from line 12
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17
18
Federal estate tax attributable to lump-sum distribution
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18
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Subtract line 18 from line 17. If line 11 is zero, skip lines 20 through 22 and go to line 23
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Divide line 11 by line 12 and enter the result as a decimal (rounded to at
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least three places) .
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20
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Multiply line 16 by the decimal on line 20
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22
Subtract line 21 from line 11
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22
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Multiply line 19 by 10% (.10)
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23
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Tax on amount on line 23. Use the Tax Rate Schedule in the instructions .
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24
25
Multiply line 24 by ten (10). If line 11 is zero, skip lines 26 through 28, enter this amount on
line 29, and go to line 30
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25
26
Multiply line 22 by 10% (.10)
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26
27
Tax on amount on line 26. Use the Tax Rate Schedule in the
instructions .
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27
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Multiply line 27 by ten (10)
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28
29
29
Subtract line 28 from line 25. Multiple recipients see instructions
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30
Tax on lump-sum distribution. Add lines 7 and 29. Also include this amount in the total on Form
1040, line 44; Form 1040NR, line 42; or Form 1041, Schedule G, line 1b .
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▶
4972
For Paperwork Reduction Act Notice, see instructions.
Form
(2015)
Cat. No. 13187U
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