pdf2json

CORRECTED (If checked) PAYER’S INFORMATION 1 Gross distribution OMB No. 1545-0119 Distributions From Payer’s Name $ Pensions, Annuities, 2a Taxable amount 2013 Retirement or Street address (including apt. no.) Profit-Sharing Plans, IRAs, $ Form 1099-R Insurance Contracts, etc. City State ZIP code 2b Taxable amount not Total Copy B determined distribution Report this Payer’s country 3 Capital gain (included 4 Federal income tax income on your in box 2a) withheld federal tax $ $ return. If this PAYER’S federal identification RECIPIENT’S identification 5 Employee contributions 6 Net unrealized form shows number number /Designated Roth appreciation in federal income contributions or employer’s securities tax withheld in RECIPIENT’S name insurance premiums box 4, attach $ $ this copy to Street address (including apt. no.) 7 Distribution IRA/ 8 Other your return. This information is City State ZIP code SIMPLE being furnished to $ % the Internal Recipient’s country 9a Your percentage of total 9b Total employee contributions Revenue Service. distribution % $ 10 Amount allocable to IRR 11 1st year of desig. Roth contrib. 12 State tax withheld 13 State/ Payer’s state no. 14 State distribution within 5 years $ / $ $ $ / $ Account number (see instructions) 15 Local tax withheld 16 Name of locality 17 Local distribution $ $ $ $ Form 1099-R Department of the Treasury - Internal Revenue Service code(s) SEP/ ----------------Page (0) Break----------------