CORRECTED (If checked)

PAYER’S INFORMATION1 Gross distributionOMB No. 1545-0119Distributions From

Payer’s Name$Pensions, Annuities,

2a Taxable amount2013Retirement or

Street address (including apt. no.)Profit-Sharing Plans, IRAs,

$Form 1099-RInsurance Contracts, etc.

CityStateZIP code2bTaxable amount notTotalCopy B

determineddistribution Report this

Payer’s country3Capital gain (included4Federal income tax income on your

 in box 2a) withheld federal tax 

$$return.  If this

PAYER’S federal identificationRECIPIENT’S identification 5Employee contributions6Net unrealized form shows

numbernumber/Designated Roth                 appreciation in federal income

contributions or employer’s securitiestax withheld in

RECIPIENT’S nameinsurance premiumsbox 4, attach

$$ this copy to

Street address (including apt. no.)7Distribution IRA/ 8Other your return.

This information is

CityState            ZIP codeSIMPLEbeing furnished to

$%the Internal

Recipient’s country9aYour percentage of total9bTotal employee contributionsRevenue Service.

distribution%$

10Amount allocable to IRR111st year of desig. Roth contrib.12State tax withheld13State/ Payer’s state no.14State distribution

within 5 years$/$

$$/$

Account number (see instructions)15Local tax withheld16Name of locality17Local distribution

$$

$$

Form 1099-RDepartment of the Treasury - Internal Revenue Service

code(s)             SEP/ 

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