Form 1099-R Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, Individual Retirement Arrangements,
Insurance
Contracts, etcetera. 2004. Summary: This is an example of Form 1099-R (2004) with information completed per the text. The line items are completed as
follows:
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“PAYER'S name, street address, city, state, and ZIP code” field contains:
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Brown's Real Estate
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Profit-Sharing Plan
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2101 Chelsea Court
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Anytown, Nevada 89300
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“PAYER'S federal identification number” field contains 10-0000000
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“RECIPIENT'S identification number” field contains 005-00-6789
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“RECIPIENT'S name” field contains Mary Brown
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“Street address (including apartment number)” field contains 12 Mill Avenue
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“City, state, and ZIP code” field contains Anytown, Nevada 89300
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“1. Gross distribution” field contains $160000.00
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“2a. Taxable amount” field contains $160000.00
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“2b. Total distribution” checkbox checked
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“4. Federal income tax withheld” field contains $32000.00
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“7. Distribution code” field contains 7A
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“8. Other” field contains $10000.00
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