EFTA01220966.pdf

Form 1099-R Distributions from Pensions, IRAs, etc 2014 • Keep for your records Name Social Security Number Source Form : 1099-R . CSA-1099-R . CSF-1099-R. RRB-1099-R . check this box • ► Corrected I-- I Payer's name, street address, city, state, and ZIP code. S S Payer's country I'M I'M Federal income Payer's Federal Recipient's tax withheld identification number identification number $ $ Check to transfer Recipient's Information from Federal Information Worksheet Recipient's name $ S street address (inducing apartment number) 1st code IM = S City State ZIP code Recipient's country % S $ 12 State tax 13 Payer's 14 State withheld State! state no. distribution special use code tor first state (see Heim P $ - - - $ Special use code for second state (See Help) . . . — S $ ft $ 15 Local tax 16 Name of 17 Local $ withheld locality $ distribution $ $ a Check if NOT from a qualified retirement plan or IRA (see Help) I. If box 7 code is J or l', check if a qualified distribution (see Help) a If box 7 code is J, enter amount used for first time home purchase S Inherfted IRA If this distribution is from an inherited IRA, indicate the distribution is from the IRA of a Treat as recipient's own (this is treated as a rollover) ii. a Recipient. but was originally inherited from a spouse (treated as recipient's IRA). . . • a Spouse and not treat as recipient's own (taxable amount must be in box 2a) ii. a Someone other than a spouse (taxable amount must be in box 2a) ii. a From a traditional IRA . a From a Roth IRA . . . . . . . . . . . . . . . . . . . . a a From a SIMPLE plan (first two years of participation only) ii. a From a SIMPLE plan (more than two years of participation) D. I. From a SEP IRA s• a None ii. a Subject to the joenally of early withdrawal ii. a Not subject to the penalty of early withdrawal . S Insurance S Amount of insurance premiums deductible on Schedule A a Amount of health savings account (HSA) funding distributions a Amount of qualified insurance premiums paid subtracted from an eligible retired public safety officer's distribution IS Qualified Charitable Distribution Enter IRA distributions made directly by the trustee to a qualified charitable organization ► RMD If this is a distribution from a traditional IRA or qualified retirement plan, and if this is a Required Minimum Distribution (RMD) (See Help), Entire gross is RMD or the amount of gross distbn that is the RMD . . Form 1099-R Additional Distribution Information 2014 EFTA01220966  Keep for your records Name Page 2 Verify Box 7 Distribution Codes (See Help) Al Check box if this is an early distribution subject to the penalty from a qualified retirement plan, traditional IRA annuity or modified endowment contract, but there is no code 1 in box 7. A2 Do not include distributions from Roth IRA or first two years of SIMPLE plans . (See Help) Check box if this is an early distribution subject to the penalty from a Roth IRA. but there is O A3 no code J in box 7. (See Help) Check box if this is an early distribution subject to the penalty from a SIMPLE plan in first two O A4 years. but there is no code S in box 7. (See Help) Check box if this is the withdrawal before tax return due date of a contribution to a traditional IRA. O Roth IRA. or a corrective distribution of an excess deferral. excess contribution, or excess aggregate contribution taxable in 2014, but there is no code 8 in box 7. (See Help) A5 Check box if there is a code P or R in box 7 and this is a year 2015 Form 1099-R. (See Help) . . . Rollovers, Roth Conversions, Roth Rollovers, and Recharacterizations Rollover: Enter traditional IRA or pension distribution that was rolled over to a pension or traditional IRA. Enter Roth IRA rollover or conversion on lines B5 or B6 below B1 B2 Check this box if the entire distribution rolled over If only part was rolled over, enter the amount of the partial rollover O B3 If box 7 code is B or H. check if the designated Roth distribution was rolled over into a Roth IRA . . . Roth IRA Rollover or Enter distribution, other than from a designated Roth, that was rolled or Roth IRA Conversion: converted to a Roth IRA including any that were later recharacterized (converted back to a traditional IRA). B4 Amount of this distribution that may be rolled or convened to a Roth IRA B5 Check this box if the entire amount on line B4 above was converted to a Roth IRA B6 If only part of the amount on line B4 above was rolled or converted to a Roth IRA. enter the amount that was converted to a Roth IRA B7 If box 7 code is G. check if an in-plan Roth rollover (IRR) to a designated Roth plan B8 Previously taxed contributions. if different than box 5, for rollover from a qualified retirement plan to Roth IRA or an in-plan Roth rollover (IRR) to a designated Roth plan Recharacterization: Caution : See Help before completing lines C2 and C3 for recharacterizations. Do not include earnings or losses when entering line C2 or C3 C1 Amount of this distribution that can be recharacterized C2 Check this box if the entire amount on line C1 above was recharacterized C3 If only part of the amount on line C1 above was recharacterized. enter the amount of line C1 that was not recharacterized (i. e. remained in the Roth IRA) Pension and Annuity Distributions Only Lump-Sum Distributions - Special Averaging Election D1 D2 Check if using 10-year averaging or making capital gain election for this distribution Enter any federal estate taxes paid on this distribution (see Help) O D3 Enter any death benefit exclusion for which you are eligible (see Help) Disability Payments - Minimum Retirement Age E Recipient was under the minimum retirement age when this distribution was received Yes I— I No I— I Charitable Gift Annuities - Capital Gains If the code in box 7 is F and there is a capital gain in box 3: F1 Enter the amount of box 3 that is taxed at the maximum 28% rate F2 Enter the amount of box 3 that is unrecaptured section 1250 gain EFTA01220967  Simplified Method Worksheet Complete if Simplified Method elected for this distribution. To elect Simplified Method. enter the annuity starting date on line 2. Name Social Security Number 1 Total pension received this year from Form 1099-R (Included on Form 1040, line 16a, or Form 1040A, line 12a) 2 Annuity starting date 2 3 Plan cost at annuity starting date 3 4 Death benefit exclusion 4 5 Add lines 3 and 4 5 6 Age (or combined ages) at annuity starting date 6 7 Age factor (payment months) 7 8 Divide line 5 by line 7 8 9 Number of months for which payments were made in 2014 9 10 Multiply line 8 by line 9 10 Note: If the annuity starting date is before 1987. enter the amount from line 10 on line 13 and skip lines 11. 12. 17. and 18. 11 Any amounts previously recovered tax free after 1986 11 12 Cost remaining at beginning of 2014. (Subtract line 11 from line 5) 12 13 Nontaxable cost. Smaller of line 10 or line 12 but no more than line 1 (if this is zero. your pension is fully taxable) 13 14 Taxable pension for year. Line 1 minus line 13 14 15 Taxable amount from Form 1099-R. box 2a 15 16 Smaller of line 14 or line 15. (Included on Form 1040, line 16b or Form 1040A, line 12b) 16 17 Total cost recovered. Add lines 11 and 13 17 18 Balance of cost to be recovered. Subtract line 17 from line 5 18 EFTA01220968