Publication 575 - Pension And Annuity Income - 2004 Page 21

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CORRECTED (if checked)
PAYER’S name, street address, city, state, and ZIP code
OMB No. 1545-0119
Distributions From
1
Gross distribution
Pensions, Annuities,
Retirement or
175000.00
$
2004
Profit-Sharing
2a Taxable amount
Crabtree Corporation Employees’ Pension Plan
Plans, IRAs,
Insurance
1111 Main Street
1099-R
150000.00
Contracts, etc.
$
Form
Anytown, Texas 75000
2b
Taxable amount
Total
Copy B
x
not determined
distribution
Report this
PAYER’S Federal identification
RECIPIENT’S identification
3 Capital gain (included
income on your
4 Federal income tax
number
number
in box 2a)
withheld
Federal tax
return. If this
form shows
30000.00
$
10-0000000
002-00-3456
10000.00
$
Federal income
RECIPIENT’S name
5
Employee contributions
6
Net unrealized
tax withheld in
or insurance premiums
appreciation in
box 4, attach
employer’s securities
this copy to
Robert C. Smith
your return.
25000.00
$
$
Street address (including apt. no.)
7
Distribution
IRA/
8 Other
SEP/
code(s)
This information is
SIMPLE
911 Mill Way
being furnished to
7A
$
%
the Internal
City, state, and ZIP code
9a
Your percentage of total
9b Total employee contributions
Revenue Service.
$
%
Anytown, Texas 75000
distribution
Account number (optional)
10
State tax withheld
11
State/Payer’s state no.
12
State distribution
$
$
$
$
13 Local tax withheld
14 Name of locality
15
Local distribution
$
$
$
$
1099-R
Form
Department of the Treasury - Internal Revenue Service
Page 21

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