Form 1099-R
Contact Information:
Name:
Email:
Phone:
Employer's name and address
1 Gross Distribution
2a Taxable amount
2b
Taxable amount not determined
Total distribution
Payer's Federal ID#
Recipient's ID#
3 Capital gain (included in box 2a)
4 Federal income tax withheld
Recipient's name and address
5 Employee contributions/Designated Roth contributions or insurance premiums
6 Net unrealized appreciation in employer's securities
7 Distribution code(s)
8 Other
9a Your percentage of total distribution
9b Total employee contributions
1st year of desig. Roth contrib.
10 State tax withheld
11 State/Payer's state no.
12 State distribution
Account number
13 Local tax withheld
14 Name of locality
15 Local Distribution