Publication 575 - Pension And Annuity Income - 2004 (Page 24 of 36) in pdf

OMB No. 1545-0193

4972

Tax on Lump-Sum Distributions

2004

Form

(From Qualified Plans of Participants Born Before January 2, 1936)

Attachment

Department of the Treasury

(99)

Attach to Form 1040 or Form 1041.

Sequence No.

Internal Revenue Service

Name of recipient of distribution

Identifying number

Mary Brown

002-00-3456

Part I

Complete this part to see if you can use Form 4972

Yes

Was this a distribution of a plan participant’s entire balance (excluding deductible voluntary employee

contributions and certain forfeited amounts) from all of an employer’s qualified plans of one kind (pension,

profit-sharing, or stock bonus)? If “No,” do not use this form

Did you roll over any part of the distribution? If “Yes,” do not use this form

Was this distribution paid to you as a beneficiary of a plan participant who was born before

January 2, 1936?

Were you (a) a plan participant who received this distribution, (b) born before January 2, 1936, and (c) a

participant in the plan for at least 5 years before the year of the distribution?

If you answered “No” to both questions 3 and 4, do not use this form.

5a Did you use Form 4972 after 1986 for a previous distribution from your own plan? If “Yes,” do not use this

form for a 2004 distribution from your own plan

If you are receiving this distribution as a beneficiary of a plan participant who died, did you use Form 4972

for a previous distribution received for that participant after 1986? If “Yes,” do not use the form for this

distribution

Part II

Complete this part to choose the 20% capital gain election

(see instructions)

Capital gain part from Form 1099-R, box 3

Multiply line 6 by 20% (.20)

If you also choose to use Part III, go to line 8. Otherwise, include the amount from line 7 in the

total on Form 1040, line 43, or Form 1041, Schedule G, line 1b, whichever applies.

Part III

Complete this part to choose the 10-year tax option

(see instructions)

Ordinary income from Form 1099-R, box 2a minus box 3. If you did not complete Part II, enter

160,000

the taxable amount from Form 1099-R, box 2a

Death benefit exclusion for a beneficiary of a plan participant who died before August 21, 1996

160,000

Total taxable amount. Subtract line 9 from line 8

10,000

Current actuarial value of annuity from Form 1099-R, box 8. If none, enter -0-

Adjusted total taxable amount. Add lines 10 and 11. If this amount is $70,000 or more, skip

170,000

lines 13 through 16, enter this amount on line 17, and go to line 18

Multiply line 12 by 50% (.50), but do not enter more than $10,000

Subtract $20,000 from line 12. If line 12 is

$20,000 or less, enter -0-

Multiply line 14 by 20% (.20)

Minimum distribution allowance. Subtract line 15 from line 13

170,000

Subtract line 16 from line 12

Federal estate tax attributable to lump-sum distribution

170,000

Subtract line 18 from line 17. If line 11 is zero, skip lines 20 through 22 and go to line 23

Divide line 11 by line 12 and enter the result as a decimal (rounded

0588

to at least three places)

Multiply line 16 by the decimal on line 20

10,000

Subtract line 21 from line 11

17,000

Multiply line 19 by 10% (.10)

2,917

Tax on amount on line 23. Use the Tax Rate Schedule in the instructions

Multiply line 24 by ten (10). If line 11 is zero, skip lines 26 through 28, enter this amount on line

29,170

29, and go to line 30

1,000

Multiply line 22 by 10% (.10)

Tax on amount on line 26. Use the Tax Rate Schedule in the

110

instructions

1,100

Multiply line 27 by ten (10)

28,070

Subtract line 28 from line 25. Multiple recipients, see instructions

Tax on lump-sum distribution. Add lines 7 and 29. Also include this amount in the total on

Form 1040, line 43, or Form 1041, Schedule G, line 1b, whichever applies

28,070

4972

For Paperwork Reduction Act Notice, see instructions.

Cat. No. 13187U

Form

(2004)

Page 24

Publication 575 - Pension And Annuity Income - 2004 Page 24

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