Description
Name:
EMail Address:
		payer 1	payer 2	payer 3	payer 4	payer 5	payer 6	payer 7
	Check if Spouse's 1099R
	Payer's ID Number
	Payer's Name
	Payer's addr Line 1
	Payer's addr Line 2
	Payer's City
	Payer's State Zip Code
1	Gross Distribution
2a	Taxable Amount
2b	Taxable Amt. Not Determined
2c	Total Distribution
3	Capital Gains in 2a
4	Federal Income Tax W/H
5	Employee Contributions
6	Net Unrealized Appreciation
7	Distribution Code
7	IRA/SEP/SIMPLE
8	Other
9a	% of total distrib.
9b	total Employee Contribution
10	State Tax withheld
11	State/Payer's state no.
12	State distribution
13	Local tax withheld
14	Name of locality
15	Local distribution