EFTA01222605.pdf

ri CORRECTED (if checked) PAYERS name. street address, city or town, state or province. 1 Gross distribution cMB No. 1545.0119 Distributions From country. and ZIP or foreign postal code Pensions, Annuities, Retirement or $ 2a Taxable amount 2017 Profit-Sharing Plans, IRAs, Insurance $ Form 1099-R Contracts, etc. 2b Taxable amount Total Copy B not determined p distribution E Report this PAYER'S federal identification RECIPIENTS identification 3 Capital gain (Included 4 Federal income tax income on your number number in box 2a) withheld federal tax return. If this form shows federal income RECIPIENT'S name 5 Employee contnbutions 6 Net unrealized tax withheld in /Designated Ro h appreciation in contributions or employers securities box 4, attach insurance premiums this copy to your return. Street address (Including apt. no.) 7 Distribution IAN 8 Other code(s) SEP/ This information is SIMPLE being furnished to 0 the Internal City or town. state or province, country, and ZIP or foreign postal code Sa Your percentage of total 9b Total employee contributions Revenue Service. distribution $ 10 Amount allocable to IRR 11 1st year of FATCA filing 12 State tax Withheld 13 State/Payer's state no. 14 State distribution within 5 years desig. Roth contrib. requirement $ $ 0 $ $ Account number (see instructions) 15 Local tax withheld 16 Name of locality 17 Local distribution $ $ $ $ Form 1099-R vonwirs.gov/form1O99r Department of the Treasury - Internal Revenue Service EFTA01222605