Form 1099-R Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, Individual Retirement Arrangements,
Insurance
Contracts, etcetera. 2005. Summary: This is an example of Form 1099-R (2005) 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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Crabtree Corporation Employees' Pension Plan
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1111 Main Street
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Anytown, Texas 75000
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“PAYER'S federal identification number” field contains 10-0000000
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“RECIPIENT'S identification number” field contains 002-00-3456
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“RECIPIENT'S name” field contains Robert C. Smith
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“Street address (including apartment number)” field contains 911 Mill Way
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“City, state, and ZIP code” field contains Anytown, Texas 75000
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“1. Gross distribution” field contains $175000.00
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“2a. Taxable amount” field contains $150000.00
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“2b. Total distribution” checkbox checked
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“3. Capital gain (included in box 2a)” field contains $10000.00
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“4. Federal income tax withheld” field contains $30000.00
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“5. Employee contributions or insurance premiums” field contains $25000.00
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“7. Distribution code” field contains 7A
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