Form 5329 Additional Taxes on Qualified Plans (Including IRAs) and Other Tax-Favored Accounts 2012

Summary: This is an example of Form 5329 (2012) as pertains to the description in the text. The line items completed are:

Name of individual subject to additional tax. If married filing jointly, see instructions. field contains Tom Jones
Your social security number field contains 004-00-0000
UnderPart I: Additional Tax on Early Distributions:
- 1. Early distributions included in income. For Roth IRA. distributions, see instructions field contains 3,000
- 2. Early distributions included on line 1 that are not subject to the additional tax (see instructions). field contains 0
- 3. Amount subject to additional tax. Subtract line 2 from line 1 field contains 3,000
- 4. Additional tax. Enter 10% (.10) of line 3. Include this amount on Form 1040, line 58, or Form 1040NR, line 56 field contains 300