Form 4972 Tax on LumpSum Distributions 2009
Summary: This is an example of Form 4972 (2009) with information pertaining to the text. The line items are completed as follows:

Name of recipient of distribution
field contains Mary Brown 
Identifying number
field contains 005006789  Under
Part I: Complete this part to see if you can use Form 4972
: 

1. Was this a distribution of a plan participant's entire balance (excluding deductible voluntary employee contributions and certain forfeited amounts) from all of an employer's qualified plans of one kind (pension, profitsharing, or stock bonus)? If No, do not use this form. YES
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2. Did you roll over any part of the distribution? If Yes, do not use this form. NO
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3. Was this distribution paid to you as a beneficiary of a plan participant who was born before 1936? NO
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4. Were you (a) a plan participant who received this distribution, (b) born before 1936, and (c) a participant in the plan for at least 5 years before the year of the distribution? YES
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5a. Did you use Form 4972 after 1986 for a previous distribution from your own plan? If Yes, do not use this form for a 2009 distribution from your own plan. NO
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 Under
Part III: Complete this part to choose the 10year tax option (see instructions)
: 

8. Ordinary income from Form 1099R, box 2a minus box 3. If you did not complete Part II, enter the taxable amount from Form 1099R, box 2a
field contains 160,000 
10. Total taxable amount. Subtract line 9 from line 8
field contains 160,000 
11. Current actuarial value of annuity from Form 1099R, box 8. If none, enter 0
field contains 10,000 
12. Adjusted total taxable amount. Add lines 10 and 11. If this amount is $70,000 or more, skip lines 13 through 16, enter this amount on line 17, and go to line 18
field contains 170,000 
17. Subtract line 16 from line 12
field contains 170,000 
19. Subtract line 18 from line 17. If line 11 is zero, skip lines 20 through 22 and go to line 23
field contains 170,000 
20. Divide line 11 by line 12 and enter the result as a decimal (rounded to at least three places)
field contains .0588 
22. Subtract line 21 from line 11
field contains 10,000 
23. Multiply line 19 by 10% (.10)
field contains 17,000 
24. Tax on amount on line 23. Use the Tax Rate Schedule in the instructions
field contains 2,917 
25. Multiply line 24 by ten (10). If line 11 is zero, skip lines 26 through 28, enter this amount on line 29, and go to line 30
field contains 29,170 
26. Multiply line 22 by 10% (.10)
field contains 1,000 
27. Tax on amount on line 26. Use the Tax Rate Schedule in the instructions
field contains 110 
28. Multiply line 27 by ten (10)
field contains 1,100 
29. Subtract line 28 from line 25. Multiple recipients, see instructions
field contains 28,070 
30. Tax on lumpsum distribution. Add lines 7 and 29. Also include this amount in the total on Form 1040, line 44, Form 1040NR, line 41, or Form 1041, Schedule G, line 1b, whichever applies
field contains 28,070
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