Form 1099-R Distributions from Pensions, IRAs, etc 2014 • Keep for your records Name Social Security Number Source Form : 1099-R . CSA-1099-R . CSF-1099-R. RRB-1099-R . check this box • ► Corrected I-- I Payer's name, street address, city, state, and ZIP code. S S I'M I'M Payer's country $ Federal income tax withheld $ Payer's Federal identification number Recipient's identification number $ S Check to transfer Recipient's Information from Federal Information Worksheet Recipient's name street address (inducing apartment number) 1st code IM = S City State ZIP code % S Recipient's country $ 12 State tax withheld $ $ 13 Payer's State! state no. - - - ft 14 State distribution $ $ special use code tor first state (see Heim P Special use code for second state (See Help) . . . — S 15 Local tax $ withheld $ 16 Name of locality 17 Local distribution $ $ a Check if NOT from a qualified retirement plan or IRA (see Help) I. If box 7 code is J or l', check if a qualified distribution (see Help) a If box 7 code is J, enter amount used for first time home purchase S Inherfted IRA If this distribution is from an inherited IRA, indicate the distribution is from the IRA of a Treat as recipient's own (this is treated as a rollover) ii. a Recipient. but was originally inherited from a spouse (treated as recipient's IRA). . . • a Spouse and not treat as recipient's own (taxable amount must be in box 2a) ii. a Someone other than a spouse (taxable amount must be in box 2a) ii. a From a traditional IRA . a From a Roth IRA . . . . . . . . . . . . . . . . . . . . a a From a SIMPLE plan (first two years of participation only) ii. a From a SIMPLE plan (more than two years of participation) D. I. From a SEP IRA s• a None ii. a Subject to the joenally of early withdrawal ii. a Not subject to the penalty of early withdrawal . S Insurance S Amount of insurance premiums