EFTA01222606.pdf

ri CORRECTED (if checked) PAYERS name. street address. city or town. state or province. 1 Gross distribution OMB No. 1515.0119 Distributions From country. ZIP or foreign postal code. and phone no. Pensions, Annuities, $2a Taxable amount 2018 Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc. Form 1099-R 2b Taxable amount Total Copy B not determined ❑ distribution E Report this PAYER'S TIN RECIPIENT'S TIN 3 Capital gain (Included 4 Federal income tax income on your in box 2a) withheld federal tax return. If this form shows federal income RECIPIENTS name 5 Employee contributions/ 6 Net unrealized tax withheld in Designated Roth appreciation in contributions or employer's securities box 4, attach insurance premiums this copy to your return. Street address Oncluding apt. no.) 7 Distribution IRA/ 8 Other code(s) SEP/ SIMPLE This information is 0 $ being furnished to City or town, state or province. country, and ZIP or foreign postal code 9a Your percentage of total 9b Total employee contributions the IRS. distribution qy $ 10 Amount allocable to IRR 11 tst year of FATCA filing 12 State tax withheld 13 State/Payer's state no. 14 State distribution within 5 years desig. Roth contrb. requrement $ $ 0 $ Account number (see instructions) Date of 15 Local tax withheld 16 Name of locality 17 Local distribution payment $ $ $ Form 1099-R wenvirs.gov/fomi1099R Department of the Treasisy - Internal Revenue Service EFTA01222606