Form 1099-R

Attention:
Copy A of this form is provided for informational purposes only. Copy A appears in red,
similar to the official IRS form. The official printed version of Copy A of this IRS form is
scannable, but the online version of it, printed from this website, is not. Do not print and file
copy A downloaded from this website; a penalty may be imposed for filing with the IRS
information return forms that can’t be scanned. See part O in the current General
Instructions for Certain Information Returns, available at www.irs.gov/form1099, for more
information about penalties.
Please note that Copy B and other copies of this form, which appear in black, may be
downloaded and printed and used to satisfy the requirement to provide the information to
the recipient.
To order official IRS information returns, which include a scannable Copy A for filing with
the IRS and all other applicable copies of the form, visit www.IRS.gov/orderforms. Click on
Employer and Information Returns, and we’ll mail you the forms you request and their
instructions, as well as any publications you may order.
Information returns may also be filed electronically using the IRS Filing Information Returns
Electronically (FIRE) system (visit www.IRS.gov/FIRE) or the IRS Affordable Care Act
Information Returns (AIR) program (visit www.IRS.gov/AIR).
See IRS Publications 1141, 1167, and 1179 for more information about printing these tax
forms.

VOID

9898

CORRECTED

PAYER’S name, street address, city or town, state or province,
country, and ZIP or foreign postal code

OMB No. 1545-0119

1 Gross distribution

2a Taxable amount

2016

$

Form

$

2b Taxable amount
not determined
PAYER’S federal identification
number

RECIPIENT’S identification
number

Total
distribution

3 Capital gain (included
in box 2a)

$
/Designated Roth
contributions or
insurance premiums

$

withheld

Copy A
For
Internal Revenue
Service Center
File with Form 1096.

6 Net unrealized
appreciation in
employer’s securities

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2016 General
Instructions for
Certain
Information
Returns.

$

7 Distribution
code(s)

Street address (including apt. no.)

4 Federal income tax

$

5 Employee contributions

RECIPIENT’S name

1099-R

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

IRA/
SEP/
SIMPLE

8 Other

$
City or town, state or province, country, and ZIP or foreign postal code 9a Your percentage of total
distribution

10 Amount allocable to IRR
within 5 years

11 1st year of
desig. Roth contrib.

FATCA filing
requirement

$

12 State tax withheld

1099-R

Cat. No. 14436Q

16 Name of locality

17 Local distribution

$
$

www.irs.gov/form1099r

Do Not Cut or Separate Forms on This Page

13 State/Payer’s state no. 14 State distribution

$
$

$
$
Form

$

$
$
15 Local tax withheld

Account number (see instructions)

%

%
9b Total employee contributions

—

Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page

VOID

CORRECTED

PAYER’S name, street address, city or town, state or province,
country, and ZIP or foreign postal code

OMB No. 1545-0119

1 Gross distribution

2a Taxable amount

2016

$

Form

$

2b Taxable amount
not determined
PAYER’S federal identification
number

RECIPIENT’S identification
number

Total
distribution

3 Capital gain (included
in box 2a)

$
/Designated Roth
contributions or
insurance premiums

$

withheld

For
State, City,
or Local
Tax Department

6 Net unrealized
appreciation in
employer’s securities

$

7 Distribution
code(s)

Street address (including apt. no.)

4 Federal income tax

Copy 1

$

5 Employee contributions

RECIPIENT’S name

1099-R

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

IRA/
SEP/
SIMPLE

8 Other

$
City or town, state or province, country, and ZIP or foreign postal code 9a Your percentage of total
distribution

10 Amount allocable to IRR
within 5 years

11 1st year of
desig. Roth contrib.

FATCA filing
requirement

$

12 State tax withheld

$
$
Form

1099-R

www.irs.gov/form1099r

$
13 State/Payer’s state no. 14 State distribution

$
$
15 Local tax withheld

Account number (see instructions)

%

%
9b Total employee contributions

$
$
16 Name of locality

17 Local distribution

$
$
Department of the Treasury - Internal Revenue Service

CORRECTED (if checked)
PAYER’S name, street address, city or town, state or province,
country, and ZIP or foreign postal code

OMB No. 1545-0119

1 Gross distribution

2a Taxable amount

2016

$

Form

$

2b Taxable amount
not determined
PAYER’S federal identification
number

RECIPIENT’S identification
number

3 Capital gain (included
in box 2a)

Report this
income on your
federal tax
return. If this
form shows
federal income
tax withheld in
box 4, attach
this copy to
your return.

4 Federal income tax
withheld

$

5 Employee contributions
/Designated Roth
contributions or
insurance premiums

$

6 Net unrealized
appreciation in
employer’s securities

$

7 Distribution
code(s)

Street address (including apt. no.)

Copy B

Total
distribution

$
RECIPIENT’S name

1099-R

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

IRA/
SEP/
SIMPLE

8 Other

This information is
being furnished to
the Internal
Revenue Service.

$
City or town, state or province, country, and ZIP or foreign postal code 9a Your percentage of total
distribution

10 Amount allocable to IRR
within 5 years

11 1st year of
desig. Roth contrib.

FATCA filing
requirement

$

12 State tax withheld

$
$
Form

1099-R

www.irs.gov/form1099r

$

13 State/Payer’s state no. 14 State distribution

$
$
15 Local tax withheld

Account number (see instructions)

%

%
9b Total employee contributions

$
$
16 Name of locality

17 Local distribution

$
$
Department of the Treasury - Internal Revenue Service

Instructions for Recipient
Generally, distributions from pensions, annuities, profit-sharing and
retirement plans (including section 457 state and local government
plans), IRAs, insurance contracts, etc., are reported to recipients on
Form 1099-R.
Qualified plans. If your annuity starting date is after 1997, you must
use the simplified method to figure your taxable amount if your payer
did not show the taxable amount in box 2a. See the instructions for
Form 1040, 1040A, or 1040NR.
IRAs. For distributions from a traditional individual retirement
arrangement (IRA), simplified employee pension (SEP), or savings
incentive match plan for employees (SIMPLE), generally the payer is
not required to compute the taxable amount. See the Form 1040,
1040A, or 1040NR instructions to determine the taxable amount. If
you are at least age 70½, you must take minimum distributions from
your IRA (other than a Roth IRA). If you do not, you are subject to a
50% excise tax on the amount that should have been distributed. See
Pub. 590-A and Pub. 590-B for more information on IRAs.
Roth IRAs. For distributions from a Roth IRA, generally the payer is
not required to compute the taxable amount. You must compute any
taxable amount on Form 8606. An amount shown in box 2a may be
taxable earnings on an excess contribution.
Loans treated as distributions. If you borrow money from a qualified
plan, section 403(b) plan, or governmental section 457(b) plan, you
may have to treat the loan as a distribution and include all or part of
the amount borrowed in your income. There are exceptions to this
rule. If your loan is taxable, Code L will be shown in box 7. See
Pub. 575.
Recipient's identification number. For your protection, this form
may show only the last four digits of your social security number
(SSN), individual taxpayer identification number (ITIN), adoption
taxpayer identification number (ATIN), or employer identification
number (EIN). However, the issuer has reported your complete
identification number to the IRS.
FATCA filing requirement. If the FATCA filing requirement box is
checked, the payer is reporting on this Form 1099 to satisfy its

chapter 4 account reporting requirement. You also may have a filing
requirement. See the Instructions for Form 8938.
Account number. May show an account or other unique number the
payer assigned to distinguish your account.
Box 1. Shows the total amount you received this year. The amount
may have been a direct rollover, a transfer or conversion to a Roth
IRA, a recharacterized IRA contribution; or you may have received it
as periodic payments, as nonperiodic payments, or as a total
distribution. Report the amount on Form 1040, 1040A, or 1040NR on
the line for “IRA distributions” or “Pensions and annuities” (or the line
for “Taxable amount”), and on Form 8606, as applicable. However, if
this is a lump-sum distribution, see Form 4972. If you have not
reached minimum retirement age, report your disability payments on
the line for “Wages, salaries, tips, etc.” on your tax return. Also report
on that line permissible withdrawals from eligible automatic
contribution arrangements and corrective distributions of excess
deferrals, excess contributions, or excess aggregate contributions
except if the distribution is of designated Roth contributions or your
after-tax contributions or if you are self-employed.
If a life insurance, annuity, qualified long-term care, or endowment
contract was transferred tax free to another trustee or contract issuer,
an amount will be shown in this box and Code 6 will be shown in box
7. If a charge or payment was made against the cash value of an
annuity contract or the cash surrender value of a life insurance
contract for the purchase of qualified long-term care insurance, an
amount will be shown in this box and Code W will be shown in box 7.
You need not report these amounts on your tax return.
Box 2a. This part of the distribution is generally taxable. If there is no
entry in this box, the payer may not have all the facts needed to figure
the taxable amount. In that case, the first box in box 2b should be
checked. You may want to get one of the free publications from the
IRS to help you figure the taxable amount. See Additional information
on the back of Copy 2. For an IRA distribution, see IRAs and Roth
IRAs on this page. For a direct rollover, other than from a qualified
plan to a Roth IRA, zero should be shown, and you must enter zero
(-0-) on the “Taxable amount” line of your tax return. If you roll over a
(Continued on the back of Copy C.)

CORRECTED (if checked)
PAYER’S name, street address, city or town, state or province,
country, and ZIP or foreign postal code

OMB No. 1545-0119

1 Gross distribution

2a Taxable amount

2016

$

Form

$

2b Taxable amount
not determined
PAYER’S federal identification
number

RECIPIENT’S identification
number

Total
distribution

3 Capital gain (included
in box 2a)

$
/Designated Roth
contributions or
insurance premiums

$

For Recipient's
Records

4 Federal income tax
withheld

6 Net unrealized
appreciation in
employer’s securities

$

7 Distribution
code(s)

Street address (including apt. no.)

Copy C

$

5 Employee contributions

RECIPIENT’S name

1099-R

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

IRA/
SEP/
SIMPLE

8 Other

This information is
being furnished to
the Internal
Revenue Service.

$
City or town, state or province, country, and ZIP or foreign postal code 9a Your percentage of total
distribution

10 Amount allocable to IRR
within 5 years

11 1st year of
desig. Roth contrib.

$
Account number (see instructions)

FATCA filing
requirement

12 State tax withheld

1099-R

(keep for your records)

$

13 State/Payer’s state no. 14 State distribution

$
$
15 Local tax withheld

$
$
Form

%

%
9b Total employee contributions

www.irs.gov/form1099r

$
$
16 Name of locality

17 Local distribution

$
$
Department of the Treasury - Internal Revenue Service

Instructions for Recipient (Continued)
distribution (other than a distribution from a designated Roth account)
from a qualified plan (including a governmental section 457(b) plan) or
section 403(b) plan to a Roth IRA, you must include on the “Taxable
amount” line of your tax return the amount shown in this box plus the
amount in box 6, if any.
If this is a total distribution from a qualified plan and you were born
before January 2, 1936 (or you are the beneficiary of someone born
before January 2, 1936), you may be eligible for the 10-year tax
option. See the Form 4972 instructions for more information.
If you are an eligible retired public safety officer who elected to
exclude from income distributions from your eligible plan used to pay
certain insurance premiums, the amount shown in box 2a has not
been reduced by the exclusion amount. See the instructions for Form
1040, 1040A, or 1040NR for more information.
Box 2b. If the first box is checked, the payer was unable to determine
the taxable amount, and box 2a should be blank, except for an IRA. It
is your responsibility to determine the taxable amount. If the second
box is checked, the distribution was a total distribution that closed out
your account.
Box 3. If you received a lump-sum distribution from a qualified plan
and were born before January 2, 1936 (or you are the beneficiary of
someone born before January 2, 1936), you may be able to elect to
treat this amount as a capital gain on Form 4972 (not on Schedule D
(Form 1040)). See the Form 4972 instructions. For a charitable gift
annuity, report as a long-term capital gain as explained in the
Instructions for Form 8949.
Box 4. Shows federal income tax withheld. Include this amount on
your income tax return as tax withheld, and if box 4 shows an amount
(other than zero), attach Copy B to your return. Generally, if you will
receive payments next year that are not eligible rollover distributions,
you can change your withholding or elect not to have income tax
withheld by giving the payer Form W-4P.
Box 5. Generally, this shows the employee’s investment in the
contract (after-tax contributions), if any, recovered tax free this year;
the portion that is your basis in a designated Roth account; the part of

premiums paid on commercial annuities or insurance contracts
recovered tax free; or the nontaxable part of a charitable gift annuity.
This box does not show any IRA contributions. If the amount shown is
your basis in a designated Roth account, the year you first made
contributions to that account may be entered in box 11.
Box 6. If you received a lump-sum distribution from a qualified plan
that includes securities of the employer’s company, the net unrealized
appreciation (NUA) (any increase in value of such securities while in
the trust) is taxed only when you sell the securities unless you choose
to include it in your gross income this year. See Pub. 575 and
Form 4972. If you roll over the distribution to a Roth IRA, see the
instructions for Box 2a. If the distribution was a direct rollover, the
NUA is included in box 2a. If you did not receive a lump-sum
distribution, the amount shown is the NUA attributable to employee
contributions, which is not taxed until you sell the securities.
Box 7. The following codes identify the distribution you received. For
more information on these distributions, see the instructions for your
tax return. Also, certain distributions may be subject to an additional
10% tax. See the Instructions for Form 5329.
1—Early distribution, no known exception (in most cases, under age
59½).
2—Early distribution, exception applies (under age 59½).
3—Disability.
4—Death.
5—Prohibited transaction.
6—Section 1035 exchange (a tax-free exchange of life insurance,
annuity, qualified long-term care insurance, or endowment
contracts).
7—Normal distribution.
8—Excess contributions plus earnings/excess deferrals (and/or
earnings) taxable in 2016.
9—Cost of current life insurance protection.
A—May be eligible for 10-year tax option (see Form 4972).
B—Designated Roth account distribution.
(Continued on the back of Copy 2.)

CORRECTED (if checked)
PAYER’S name, street address, city or town, state or province,
country, and ZIP or foreign postal code

OMB No. 1545-0119

1 Gross distribution

2a Taxable amount

2016

$

Form

$

2b Taxable amount
not determined
PAYER’S federal identification
number

RECIPIENT’S identification
number

Total
distribution

3 Capital gain (included
in box 2a)

$
/Designated Roth
contributions or
insurance premiums

$

4 Federal income tax
withheld

6 Net unrealized
appreciation in
employer’s securities

$

7 Distribution
code(s)

Street address (including apt. no.)

Copy 2
File this copy
with your state,
city, or local
income tax
return, when
required.

$

5 Employee contributions

RECIPIENT’S name

1099-R

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

IRA/
SEP/
SIMPLE

8 Other

$
City or town, state or province, country, and ZIP or foreign postal code 9a Your percentage of total
distribution

10 Amount allocable to IRR
within 5 years

11 1st year of
desig. Roth contrib.

FATCA filing
requirement

$

12 State tax withheld

$
$
Form

1099-R

www.irs.gov/form1099r

$
13 State/Payer’s state no. 14 State distribution

$
$
15 Local tax withheld

Account number (see instructions)

%

%
9b Total employee contributions

$
$
16 Name of locality

17 Local distribution

$
$
Department of the Treasury - Internal Revenue Service

Instructions for Recipient (Continued)
Note: If Code B is in box 7 and an amount is reported in box 10,
see the Instructions for Form 5329.
D—Annuity payments from nonqualified annuities that may be subject
to tax under section 1411.
E—Distributions under Employee Plans Compliance Resolution
System (EPCRS).
F—Charitable gift annuity.
G—Direct rollover of a distribution to a qualified plan, a section 403(b)
plan, a governmental section 457(b) plan, or an IRA.
H—Direct rollover of a designated Roth account distribution to a Roth
IRA.
J—Early distribution from a Roth IRA, no known exception (in most
cases, under age 59½).
K—Distribution of traditional IRA assets not having a readily available
FMV.
L—Loans treated as distributions.
N—Recharacterized IRA contribution made for 2016 and
recharacterized in 2016.
P—Excess contributions plus earnings/excess deferrals (and/or
earnings) taxable in 2015.
Q—Qualified distribution from a Roth IRA.
R—Recharacterized IRA contribution made for 2015 and
recharacterized in 2016.
S—Early distribution from a SIMPLE IRA in first 2 years, no known
exception (under age 59½).
T—Roth IRA distribution, exception applies.
U—Dividend distribution from ESOP under section 404(k).
Note: This distribution is not eligible for rollover.
W—Charges or payments for purchasing qualified long-term care
insurance contracts under combined arrangements.
If the IRA/SEP/SIMPLE box is checked, you have received a
traditional IRA, SEP, or SIMPLE distribution.

Box 8. If you received an annuity contract as part of a distribution,
the value of the contract is shown. It is not taxable when you receive it
and should not be included in boxes 1 and 2a. When you receive
periodic payments from the annuity contract, they are taxable at that
time. If the distribution is made to more than one person, the
percentage of the annuity contract distributed to you is also shown.
You will need this information if you use the 10-year tax option (Form
4972). If charges were made for qualified long-term care insurance
contracts under combined arrangements, the amount of the reduction
in the investment (but not below zero) in the annuity or life insurance
contract is reported here.
Box 9a. If a total distribution was made to more than one person, the
percentage you received is shown.
Box 9b. For a life annuity from a qualified plan or from a section
403(b) plan (with after-tax contributions), an amount may be shown for
the employee’s total investment in the contract. It is used to compute
the taxable part of the distribution. See Pub. 575.
Box 10. If an amount is reported in this box, see the Instructions for
Form 5329 and Pub. 575.
Box 11. The 1st year you made a contribution to the designated Roth
account reported on this form is shown in this box.
Boxes 12–17. If state or local income tax was withheld from the
distribution, boxes 14 and 17 may show the part of the distribution
subject to state and/or local tax.
Future developments. For the latest information about developments
related to Form 1099-R and its instructions, such as legislation
enacted after they were published, go to www.irs.gov/form1099r.
Additional information. You may want to see:
Form W-4P
Form 4972
Form 5329
Form 8606
Pub. 560
Pub. 571

Pub. 575
Pub. 590-A
Pub. 590-B
Pub. 721
Pub. 939
Pub. 969

VOID

CORRECTED

PAYER’S name, street address, city or town, state or province,
country, and ZIP or foreign postal code

OMB No. 1545-0119

1 Gross distribution

2a Taxable amount

2016

$

Form

$

2b Taxable amount
not determined
PAYER’S federal identification
number

RECIPIENT’S identification
number

Total
distribution

3 Capital gain (included
in box 2a)

$
/Designated Roth
contributions or
insurance premiums

$

For Payer

4 Federal income tax
withheld

6 Net unrealized
appreciation in
employer’s securities

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2016 General
Instructions for
Certain
Information
Returns.

$

7 Distribution
code(s)

Street address (including apt. no.)

Copy D

$

5 Employee contributions

RECIPIENT’S name

1099-R

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

IRA/
SEP/
SIMPLE

8 Other

$
City or town, state or province, country, and ZIP or foreign postal code 9a Your percentage of total
distribution

10 Amount allocable to IRR
within 5 years

11 1st year of
desig. Roth contrib.

FATCA filing
requirement

$

12 State tax withheld

$
$
Form

1099-R

www.irs.gov/form1099r

$

13 State/Payer’s state no. 14 State distribution

$
$
15 Local tax withheld

Account number (see instructions)

%

%
9b Total employee contributions

$
$
16 Name of locality

17 Local distribution

$
$
Department of the Treasury - Internal Revenue Service

Instructions for Payer
To complete Form 1099-R, use:
• the 2016 General Instructions for Certain
Information Returns, and
• the 2016 Instructions for Forms 1099-R and
5498.
To order these instructions and additional
forms, go to www.irs.gov/form1099r.
Caution: Because paper forms are scanned
during processing, you cannot file Forms
1096, 1097, 1098, 1099, 3921, 3922, or 5498
that you print from the IRS website.
Due dates. Furnish Copies B, C, and 2 of this
form to the recipient by January 31, 2017.

File Copy A of this form with the IRS by
February 28, 2017. If you file electronically, the
due date is March 31, 2017. To file
electronically, you must have software that
generates a file according to the specifications
in Pub. 1220. The IRS does not provide a fill-in
form option.
Need help? If you have questions about
reporting on Form 1099-R, call the information
reporting customer service site toll free at
1-866-455-7438 or 304-263-8700 (not toll
free). Persons with a hearing or speech
disability with access to TTY/TDD equipment
can call 304-579-4827 (not toll free).