Form 1099-R

Distributions From Pensions, Annuities, IRAs, etc.

Retirement-plan and IRA distributions, with taxable amount and codes.

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Issuer / payer

The business or person that paid and is filing this return. Enter either a business name or an individual name.

Foreign entityIssuer TIN *TIN type *Business name controlFirst 4 significant characters of the business name.Business nameBusiness name (line 2)Individual first nameIndividual middle nameIndividual last nameForeign addressCheck to enter a non-US address (country + province + postal code).Address line 1 *Address line 2City *State (US address)Required for a US address.ZIP code (US address)Province / region (foreign)Country code (foreign)Two-letter ISO country code for a foreign address.Postal code (foreign)Phone number

Recipient / payee

The person or business that received the payment. Enter either a business name or an individual name.

Recipient TINTIN typeBusiness name controlBusiness nameBusiness name (line 2)Individual first nameIndividual middle nameIndividual last nameAdditional recipientForeign addressCheck to enter a non-US address (country + province + postal code).Address line 1 *Address line 2City *State (US address)Required for a US address.ZIP code (US address)Province / region (foreign)Country code (foreign)Two-letter ISO country code for a foreign address.Postal code (foreign)Account numberDistinguishes this recipient if you file more than one of the same form for them.

Filing details

Tax year *VoidCorrectedCombined Federal/State Filing — stateElect to have the IRS forward this record to a participating state.

Form 1099-R details

1Gross distribution2aTaxable amount2bTaxable amount not determined2bTotal distribution3Capital gain (included in box 2a)4Federal income tax withheld5Employee contributions / designated Roth contributions or insurance premiums6Net unrealized appreciation in employer's securities7Distribution code(s)7IRA / SEP / SIMPLE8Other distribution amount8Other distribution percentage9aYour percentage of total distribution9bTotal employee contributions10Amount allocable to IRR within 5 years11First year of designated Roth contributions12FATCA filing requirement13Date of payment

State & local tax

Add a row per state where tax was withheld. Leave empty if none.

State & local tax #1

State *State ID numberState tax withheldState incomeState distributionLocal tax withheldLocal incomeLocality nameSpecial data entries

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