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This form is provided for informational purposes only. Copy A appears in red,
similar to the official IRS form. Do not file copy A with the IRS. The official printed
version of this IRS form is scannable, but the online version of it, printed from this
website, is not. A penalty of $50 per information return may be imposed for filing
forms that cannot be scanned.
See IRS Publications 1141, 1167, 1179 and other IRS resources for information
about printing these tax forms.
TLS, have you Page 1 of 12 of Form 1099-R (Page 2 is Blank) 4 Action Date Signature
transmitted all R
text files for this O.K. to print
cycle update? The type and rule above prints on all proofs including departmental
reproduction proofs. MUST be removed before printing. T:FP:F
O.K. to print
Date
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scan organization
Revised proofs
INK: Red, J-6983 - Separation for Form 1099-R Page 1 requested
INK: Black - Separation for Form 1099-R Page 1
Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page
Page 3 of 12 of Form 1099-R (Page 4 is blank) 4
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VOID CORRECTED
PAYER’S name, street address, city, state, and ZIP code 1 Gross distribution OMB No. 1545-0119 Distributions From
Pensions, Annuities,
Retirement or
$
2a Taxable amount 2007 Profit-Sharing
Plans, IRAs,
Insurance
Contracts, etc.
$ Form 1099-R
2b Taxable amount Total Copy 1
not determined distribution
For
PAYER’S federal identification RECIPIENT’S identification 3 Capital gain (included 4 Federal income tax State, City,
number number in box 2a) withheld or Local
Tax Department
$ $
RECIPIENT’S name 5 Employee contributions 6 Net unrealized
/Designated Roth appreciation in
contributions or employer’s securities
insurance premiums
$ $
Street address (including apt. no.) 7 Distribution IRA/ 8 Other
code(s) SEP/
SIMPLE
$ %
City, state, and ZIP code 9a Your percentage of total 9b Total employee contributions
distribution % $
1st year of desig. Roth contrib. 10 State tax withheld 11 State/Payer’s state no. 12 State distribution
$ $
$ $
Account number (see instructions) 13 Local tax withheld 14 Name of locality 15 Local distribution
$ $
$ $
Form 1099-R Department of the Treasury — Internal Revenue Service
Page 5 of 12 of Form 1099-R 4
The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.
$ $
RECIPIENT’S name 5 Employee contributions 6 Net unrealized
/Designated Roth appreciation in
contributions or employer’s securities
insurance premiums
$ $
Street address (including apt. no.) 7 Distribution IRA/ 8 Other
code(s) SEP/ This information is
SIMPLE
being furnished to
$ % the Internal
City, state, and ZIP code 9a Your percentage of total 9b Total employee contributions Revenue Service.
distribution % $
1st year of desig. Roth contrib. 10 State tax withheld 11 State/Payer’s state no. 12 State distribution
$ $
$ $
Account number (see instructions) 13 Local tax withheld 14 Name of locality 15 Local distribution
$ $
$ $
Form 1099-R (keep for your records) Department of the Treasury — Internal Revenue Service
Page 8 of 12 of Form 1099-R 4
The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.
VOID CORRECTED
PAYER’S name, street address, city, state, and ZIP code 1 Gross distribution OMB No. 1545-0119 Distributions From
Pensions, Annuities,
Retirement or
$
2a Taxable amount 2007 Profit-Sharing
Plans, IRAs,
Insurance
Contracts, etc.
$ Form 1099-R
2b Taxable amount Total Copy D
not determined distribution
For Payer
PAYER’S federal identification RECIPIENT’S identification 3 Capital gain (included 4 Federal income tax
number number in box 2a) withheld
$ $
RECIPIENT’S name 5 Employee contributions 6 Net unrealized
/Designated Roth appreciation in For Privacy Act
contributions or employer’s securities and Paperwork
insurance premiums Reduction Act
$ $ Notice, see the
Street address (including apt. no.) 7 Distribution IRA/ 8 Other 2007 General
code(s) SEP/ Instructions for
SIMPLE
Forms 1099,
$ %
1098, 5498,
City, state, and ZIP code 9a Your percentage of total 9b Total employee contributions and W-2G.
distribution % $
1st year of desig. Roth contrib. 10 State tax withheld 11 State/Payer’s state no. 12 State distribution
$ $
$ $
Account number (see instructions) 13 Local tax withheld 14 Name of locality 15 Local distribution
$ $
$ $
Form 1099-R Department of the Treasury — Internal Revenue Service
Page 12 of 12 of Form 1099-R 4
The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.