Publication 575: Pension and Annuity Income;

This is archived information that pertains only to the 2004 Tax Year. If you
are looking for information for the current tax year, go to the Tax Prep Help Area.

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:

“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