Form 1099-R Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc. 2008

Summary: This is an example of Form 1099-R (2008) with information completed per the text. The line items are completed as follows:

“PAYER'S name, street address, city, state, and ZIP code” field contains:

Crabtree Corporation Employees' Pension Plan 1111 Main Street Anytown, Texas 75000

“PAYER'S federal identification number” field contains 10-0000000

“RECIPIENT'S identification number” field contains 002-00-3456

“RECIPIENT'S name” field contains Robert C. Smith

“RECIPIENT'S identification number” field contains 002-00-3456

“Street address (including apartment number)” field contains 911 Mill Way “City, state, and ZIP code” field contains Anytown, Texas 75000

“1. Gross distribution” field contains $175000.00

“2a. Taxable amount” field contains $150000.00

“2b. Total distribution” checkbox checked

“3. Capital gain (included in box 2a)” field contains $10000.00

“4. Federal income tax withheld” field contains $30000.00

“5. Employee contributions or insurance premiums” field contains $25000.00

“7. Distribution code” field contains 7A