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:
- Brown's Real Estate
- Profit-Sharing Plan
- 2101 Chelsea Court
- Anytown, Nevada 89300
PAYER'S federal identification number field contains 10-0000000
RECIPIENT'S identification number field contains 005-00-6789
RECIPIENT'S name field contains Mary Brown
- Street address (including apt. no.) field contains 12 Mill Avenue
- City, state, and ZIP code field contains Anytown, Nevada 89300
1. Gross distribution field contains $160000.00
2a. Taxable amount field contains $160000.00
2b. Total distribution checkbox checked
4. Federal income tax withheld field contains $32000.00
7. Distribution code(s) field contains 7A
8. Other field contains $10000.00