Form 1099-R (Distributions from Pensions, Annuities, Retirement...)

Please complete the form below by entering the information EXACTLY as it appears on your Form 1099-R
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* Your email Address:

* PAYER’S name, street address, city, state, and ZIP code

1 Gross distribution

2001

Form 1099-R

Distributions From Pensions, Annuities, Retirement or
Profit Sharing Plans, IRAs, Insurance Contracts, etc.

2a Taxable amount

2b Taxable amount
not determined

Total
Distribution

* PAYER’S ID number

* RECIPIENT’S ID number

3 Capital gain (included
in box 2a)

4 Federal income tax w/h

* RECIPIENT'S name, street address, city, state, and ZIP

5 Employee contributions
or insurance premiums

6 Net unrealized appreciation in employer’s securities

7 Distribution IRA/SEP
code SIMPLE

8 Other
%

9a Your percentage of total distribution %

9b Total employee contrib.

Account number (optional)

10 State tax withheld

11 State/Payer's state no.

12 State distribution

13 Local tax withheld

14 Name of locality

15 Local distribution

Form 1099-R

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