Form 1099-R Distributions From Pensions, Annuities, Retirement or Pr

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, ZIP or foreign postal code, and telephone no.

1 Gross distribution

OMB No. 1545-0119

2a Taxable amount

2021

$

Form

$

2b Taxable amount
not determined
PAYER’S TIN

RECIPIENT’S TIN

RECIPIENT’S name

Total
distribution

Copy A

3 Capital gain (included in 4 Federal income tax
withheld
box 2a)

For
Internal Revenue
Service Center

$

$

File with Form 1096.

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.)

1099-R

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

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2021 General
Instructions for
Certain
Information
Returns.

IRA/
8 Other
SEP/
SIMPLE

$
%
City or town, state or province, country, and ZIP or foreign postal code 9a Your percentage of total 9b Total employee contributions
distribution
%$
10 Amount allocable to IRR
within 5 years

11 1st year of desig. 12 FATCA filing 14 State tax withheld
requirement
Roth contrib.
$

$

$
$

$

Account number (see instructions)

Form

15 State/Payer’s state no. 16 State distribution

1099-R

Cat. No. 14436Q

13 Date of
payment

17 Local tax withheld

$
$

19 Local distribution

$
$

www.irs.gov/Form1099R

Do Not Cut or Separate Forms on This Page

18 Name of locality

—

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, ZIP or foreign postal code, and telephone no.

1 Gross distribution

OMB No. 1545-0119

2a Taxable amount

2021

$

Form

$

2b Taxable amount
not determined
PAYER’S TIN

1099-R

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

Total
distribution

3 Capital gain (included in 4 Federal income tax
withheld
box 2a)

RECIPIENT’S TIN

RECIPIENT’S name

$

$

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 1
For
State, City,
or Local
Tax Department

IRA/
8 Other
SEP/
SIMPLE

$
%
City or town, state or province, country, and ZIP or foreign postal code 9a Your percentage of total 9b Total employee contributions
distribution
%$
10 Amount allocable to IRR
within 5 years

11 1st year of desig. 12 FATCA filing 14 State tax withheld
requirement
Roth contrib.
$

$

$
$

$

Account number (see instructions)

Form

15 State/Payer’s state no. 16 State distribution

1099-R

13 Date of
payment
www.irs.gov/Form1099R

17 Local tax withheld

$
$

18 Name of locality

19 Local distribution

$
$
Department of the Treasury - Internal Revenue Service

CORRECTED (if checked)
PAYER’S name, street address, city or town, state or province,
country, ZIP or foreign postal code, and telephone no.

1 Gross distribution

OMB No. 1545-0119

2a Taxable amount

2021

$

Form

$

2b Taxable amount
not determined
PAYER’S TIN

1099-R

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

Total
distribution

Copy B
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.

3 Capital gain (included in 4 Federal income tax
withheld
box 2a)

RECIPIENT’S TIN

RECIPIENT’S name

$

$

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.)

IRA/
8 Other
SEP/
SIMPLE

$

This information is
being furnished to
the IRS.

%

City or town, state or province, country, and ZIP or foreign postal code 9a Your percentage of total 9b Total employee contributions
distribution
%$
10 Amount allocable to IRR
within 5 years

11 1st year of desig. 12 FATCA filing 14 State tax withheld
requirement
Roth contrib.
$

$

$
$

$

Account number (see instructions)

Form

15 State/Payer’s state no. 16 State distribution

1099-R

13 Date of
payment
www.irs.gov/Form1099R

17 Local tax withheld

$
$

18 Name of locality

19 Local distribution

$
$
Department of the Treasury - Internal Revenue Service

Instructions for Recipient

Generally, distributions from retirement plans (IRAs, qualified plans,
section 403(b) plans, and governmental section 457(b) plans),
insurance contracts, etc., are reported to recipients on Form 1099-R.
Qualified plans and section 403(b) plans. If your annuity starting
date is after 1997, you must use the simplified method to figure your
taxable amount if your payer didn’t show the taxable amount in box
2a. See the instructions for your tax return.
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 isn’t
required to compute the taxable amount. See the instructions for your
tax return to determine the taxable amount. If you’re at least age 72,
you must take minimum distributions from your IRA (other than a Roth
IRA). If you don’t, you’re subject to a 50% excise tax on the amount
that should’ve 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 isn’t
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 taxpayer identification number (TIN). For your
protection, this form may show only the last four digits of your TIN
(SSN, ITIN, ATIN, or EIN). However, the payer has reported your
complete TIN to the IRS.
Account number. May show an account, policy, or other unique
number the payer assigned to distinguish your account.
Box 1. Shows the total amount distributed 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, nonperiodic payments, or a total distribution.
Report the amount on Form 1040, 1040-SR, or 1040-NR 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 haven’t 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’re 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. If code C is
shown in box 7, the amount shown in box 1 is a receipt of reportable
death benefits that is taxable in part.
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, earlier.
For a direct rollover, other than from a qualified plan, section 403(b)
plan, or governmental section 457(b) plan to a designated Roth account
in the same plan or 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 distribution (other than a distribution from a designated Roth
account) from a qualified plan, section 403(b) plan, or governmental
section 457(b) plan to a designated Roth account in the same plan or to
(Continued on the back of Copy C)

CORRECTED (if checked)
PAYER’S name, street address, city or town, state or province,
country, ZIP or foreign postal code, and telephone no.

1 Gross distribution

OMB No. 1545-0119

2a Taxable amount

2021

$

Form

$

2b Taxable amount
not determined
PAYER’S TIN

1099-R

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

Total
distribution

Copy C
For Recipient’s
Records

3 Capital gain (included in 4 Federal income tax
withheld
box 2a)

RECIPIENT’S TIN

RECIPIENT’S name

$

$

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.)

IRA/
8 Other
SEP/
SIMPLE

$

This information is
being furnished to
the IRS.

%

City or town, state or province, country, and ZIP or foreign postal code 9a Your percentage of total 9b Total employee contributions
distribution
%$
10 Amount allocable to IRR
within 5 years

11 1st year of desig. 12 FATCA filing 14 State tax withheld
requirement
Roth contrib.
$

$

$
$

$

Account number (see instructions)

Form

15 State/Payer’s state no. 16 State distribution

1099-R

(keep for your records)

13 Date of
payment

17 Local tax withheld

$
$

www.irs.gov/Form1099R

18 Name of locality

19 Local distribution

$
$
Department of the Treasury - Internal Revenue Service

Instructions for Recipient (continued)

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’re 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’re 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 hasn’t been
reduced by the exclusion amount. See the instructions for your tax
return 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’s 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’re 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
receive payments that aren’t 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’s your basis in a designated Roth account; the part of
premiums paid on commercial annuities or insurance contracts
recovered tax free; the nontaxable part of a charitable gift annuity; or
the investment in a life insurance contract reportable under section
6050Y. This box doesn’t 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 designated Roth
account in the same plan or to a Roth IRA, see the instructions for box
2a. For a direct rollover to a designated Roth account in the same plan
or to a Roth IRA, the NUA is included in box 2a. If you didn’t receive a
lump-sum distribution, the amount shown is the NUA attributable to
employee contributions, which isn’t 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 2021.
9—Cost of current life insurance protection.
A—May be eligible for 10-year tax option (see Form 4972).
B—Designated Roth account distribution.
Note: If code B is in box 7 and an amount is reported in box 11,
see the Instructions for Form 5329.
C—Reportable death benefits under section 6050Y.
D—Annuity payments from nonqualified annuities that may be subject
to tax under section 1411.
E—Distributions under Employee Plans Compliance Resolution
System (EPCRS).
(Continued on the back of Copy 2)

CORRECTED (if checked)
PAYER’S name, street address, city or town, state or province,
country, ZIP or foreign postal code, and telephone no.

1 Gross distribution

OMB No. 1545-0119

2a Taxable amount

2021

$

Form

$

2b Taxable amount
not determined
PAYER’S TIN

1099-R

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

Total
distribution

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

3 Capital gain (included in 4 Federal income tax
withheld
box 2a)

RECIPIENT’S TIN

RECIPIENT’S name

$

$

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.)

IRA/
8 Other
SEP/
SIMPLE

$
%
City or town, state or province, country, and ZIP or foreign postal code 9a Your percentage of total 9b Total employee contributions
distribution
%$
10 Amount allocable to IRR
within 5 years

11 1st year of desig. 12 FATCA filing 14 State tax withheld
requirement
Roth contrib.
$

$

$
$

$

Account number (see instructions)

Form

15 State/Payer’s state no. 16 State distribution

1099-R

13 Date of
payment
www.irs.gov/Form1099R

17 Local tax withheld

$
$

18 Name of locality

19 Local distribution

$
$
Department of the Treasury - Internal Revenue Service

Instructions for Recipient (continued)

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.
M—Qualified plan loan offset.
N—Recharacterized IRA contribution made for 2021 and
recharacterized in 2021.
P—Excess contributions plus earnings/excess deferrals (and/or
earnings) taxable in 2020.
Q—Qualified distribution from a Roth IRA.
R—Recharacterized IRA contribution made for 2020 and
recharacterized in 2021.
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 isn’t 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’ve 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 isn’t taxable when you receive it and
shouldn’t be included in boxes 1 and 2a. When you receive periodic
payments from the annuity contract, they’re 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’ll 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 first year you made a contribution to the designated Roth
account reported on this form is shown in this box.
Box 12. If checked, the payer is reporting on this Form 1099 to satisfy
its Internal Revenue Code chapter 4 account reporting requirement
under FATCA. You may also have a filing requirement. See the
Instructions for Form 8938.
Box 13. Shows the date of payment for reportable death benefits
under section 6050Y.
Boxes 14–19. If state or local income tax was withheld from the
distribution, boxes 16 and 19 may show the part of the distribution
subject to state and/or local tax.
Additional information. You may want to see:
Form W-4P, Form 4972, Form 5329, Form 8606
Pub. 525, Taxable and Nontaxable Income
Pub. 560, Retirement Plans for Small Business
Pub. 571, Tax-Sheltered Annuity Plans
Pub. 575, Pension and Annuity Income
Pub. 590-A, Contributions to IRAs
Pub. 590-B, Distributions from IRAs
Pub. 721, U.S. Civil Service Retirement Benefits
Pub. 939, General Rule for Pensions and Annuities
Pub. 969, HSAs and Other Tax-Favored Health Plans

VOID

CORRECTED

PAYER’S name, street address, city or town, state or province,
country, ZIP or foreign postal code, and telephone no.

1 Gross distribution

OMB No. 1545-0119

2a Taxable amount

2021

$

Form

$

2b Taxable amount
not determined
PAYER’S TIN

1099-R

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

Total
distribution

Copy D
For Payer

3 Capital gain (included in 4 Federal income tax
withheld
box 2a)

RECIPIENT’S TIN

RECIPIENT’S name

$

$

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.)

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2021 General
Instructions for
Certain
Information
Returns.

IRA/
8 Other
SEP/
SIMPLE

$
%
City or town, state or province, country, and ZIP or foreign postal code 9a Your percentage of total 9b Total employee contributions
distribution
%$
10 Amount allocable to IRR
within 5 years

11 1st year of desig. 12 FATCA filing 14 State tax withheld
requirement
Roth contrib.
$

$

$
$

$

Account number (see instructions)

Form

15 State/Payer’s state no. 16 State distribution

1099-R

13 Date of
payment
www.irs.gov/Form1099R

17 Local tax withheld

$
$

18 Name of locality

19 Local distribution

$
$
Department of the Treasury - Internal Revenue Service

Instructions for Payer
To complete Form 1099-R, use:
• The 2021 General Instructions for Certain
Information Returns, and
• The 2021 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, 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, 2022.

File Copy A of this form with the IRS by
February 28, 2022. If you file electronically, the
due date is March 31, 2022. 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 for Copy A.
Need help? If you have questions about
reporting on Form 1099-R, call the information
reporting customer service site toll free at
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).