Form 1099-R Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc. 2012

Summary: This is an example of Form 1099-R (2012) 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
RECIPIENT'S identification number field contains 002-00-3456
- 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/Designated Roth contributions or insurance premiums field contains $25000.00
7. Distribution code(s) field contains 7A