Form 1099-R - Distributions From Pensions, Annuities, Retirement Or Profit-Sharing Plans, Iras, Insurance Contracts, Etc. - 2017

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CORRECTED (if checked)

Distributions From

PAYER’S name, street address, city or town, state or province,

1 Gross distribution

OMB No. 1545-0119

Pensions, Annuities,

country, and ZIP or foreign postal code

Retirement or

2017

$

Profit-Sharing

2a Taxable amount

Plans, IRAs,

Insurance

Contracts, etc.

1099-R

$

Form

Copy B

2b Taxable amount

Total

not determined

distribution

Report this

income on your

PAYER’S federal identification

RECIPIENT’S identification

3 Capital gain (included

4

Federal income tax

in box 2a)

withheld

federal tax

number

number

return. If this

form shows

$

$

federal income

RECIPIENT’S name

5

6 Net unrealized

Employee contributions

tax withheld in

/Designated Roth

appreciation in

box 4, attach

contributions or

employer’s securities

this copy to

insurance premiums

your return.

$

$

Street address (including apt. no.)

7 Distribution

IRA/

8 Other

SEP/

This information is

code(s)

SIMPLE

being furnished to

$

%

the Internal

9b

9a

Total employee contributions

City or town, state or province, country, and ZIP or foreign postal code

Your percentage of total

Revenue Service.

distribution

$

%

10

11 1st year of

12

13 State/Payer’s state no. 14 State distribution

Amount allocable to IRR

FATCA filing

State tax withheld

requirement

within 5 years

desig. Roth contrib.

$

$

$

$

$

Account number (see instructions)

15

16 Name of locality

17 Local distribution

Local tax withheld

$

$

$

$

1099-R

Form

Department of the Treasury - Internal Revenue Service

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