Form 1099-R Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, Individual Retirement Arrangements, Insurance Contracts, etcetera. 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:

Brown's Real Estate Profit-Sharing Plan 2101 Chelsea Court Anytown, Nevada 89300

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

“RECIPIENT'S identification number” field contains 005-00-6789

“RECIPIENT'S name” field contains Mary Brown

“Street address (including apt. number)” field contains 12 Mill Avenue “City, state, and ZIP code” field contains Anytown, Nevada 89300

“1. Gross distribution” field contains $160000.00

“2a. Taxable amount” field contains $160000.00

“2b. Total distribution” checkbox checked

“4. Federal income tax withheld” field contains $32000.00

“7. Distribution code” field contains 7A

“8. Other” field contains $10000.00