Publication 1436 (Rev. 10-2012) - Internal Revenue Service

CORRECTED (if checked)
PAYER’S name, street address, city, state, and ZIP code
1 Gross distribution
2079
$
2a Taxable amount
Sandy School District
636 Guava St.
Sandy, OR 97055
PAYER’S federal identification
number
69-0000017
RECIPIENT’S identification
number
$
2b Taxable amount
not determined
3 Capital gain (included
in box 2a)
OMB No. 1545-0119
2012
Form 1099-R
Total
distribution
4 Federal income tax
withheld
DRAFT AS OF
$
400-00-1038
2079
$
6 Net unrealized
appreciation in
employer’s securities
Version A, Cycle 7
Image Dimensions: 7.3" x 5.1"
Distributions From
Pensions, Annuities,
Retirement or
Profit-Sharing
Plans, IRAs,
Insurance
Contracts, etc.
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.
RECIPIENT’S name
5 Employee contributions
Oscar Dahlia
/Designated Roth
contributions or
insurance premiums
$
$
Street address (including apt. no.)
123 Guava St.
City, state, and ZIP code
Sandy, OR 97055
7 Distribution IRA/ 8 Other
code(s)
SEP/
SIMPLE
2
$ %
9a Your percentage of total 9b Total employee contributions
distribution % $
being furnished to
the Internal
Revenue Service.
10 Amount allocable to IRR 11 1st year of desig. Roth contrib. 12 State tax withheld 13 State/Payer’s state no. 14 State distribution
within 5 years
$
$
$
$
$
Account number (see instructions)
15 Local tax withheld 16 Name of locality 17 Local distribution
$
$
$
$
Form 1099-R
www.irs.gov/form1099r
Department of the Treasury - Internal Revenue Service
February 16, 2012This
information is
107