IRS Form 1099-R – Retirement Income

Please fill out all of the information below from your IRS form. If there is nothing in the box on your form, just leave the field blank. Round all amounts to the nearest dollar (no cents).

Email Address*
Please fill out all of the information below from your IRS 1099-R form. If there is nothing in the box on your 1099-R, just leave the field blank. Round all amounts to the nearest dollar (no cents).
Void
- Yes
Corrected
- Yes
Payer's Name
First Last
Payer's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Payer's Telephone
Payer's Federal ID #
Recipient's ID #
Recipient's Name
Recipient's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Account Number (optional)
Box 1 - Gross distribution
Box 2a - Taxable amount
Box 2b
Box 3 - Capital gain (included in box 2a)
Box 4 - Federal tax withheld
Box 5 - Employee contributions or insurance premiums
Box 6 - Net unrealized appreciation in employer’s securities
Box 7 - Distribution code(s)
IRA/SEP/Simple
Box 8 - Other
Box 9a - Your percentage of total distribution
Box 9b - Total employee contributions
Box 10 - State tax withheld
Box 11 - State/Payer’s state no.
Box 12 - State distribution
Box 13 - Local tax withheld
Box 14 - Name of locality
Box 15 - Local distribution
Special Notes
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