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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:

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
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