Reporting Year

Last Name

First Name

Middle Name

Address 1

Address 2

Address 3

City

State

Zip Code

Employee ID

Social Security Number

Department

Gross Distribution

Taxable Amount Not Determined

Taxable Amt Dtrmnd 1099

Total Distribution CB

Capital Gain

Federal Income Tax W/H

Employee Contributions

Net Realized Appreciation

Distribution Code 1

Distribution Code 2

Distribution Code 3

IRA/SEP CB

Other Amount 1099-R

Other Percentage 1099-R

Total Distribution Percentage

State Wages-1

State Wages-2

State Income Tax-1

State Income Tax-2

State Code-1

State Code-2

Employer State ID Number-1

Employer State ID Number-2

Local Wages-1

Local Wages-2

Local Income Tax-1

Local Income Tax-2

Local Code-1

Local Code-2

Year End 1099R Forms Count

Employee Suffix