VOID

CORRECTED

PAYER'S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no.

, , , , ,

1	Gross distribution
$

OMB No. 1545-0119

24

From1099-R

Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc.

2a	Taxable amount
$

Taxable amount not
determined

Total
distribution

PAYER'S TIN

RECIPIENT'S TIN

3	Capital gain (included in box 2a)
$

4	Federal income tax withheld
$

RECIPIENT'S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

, , ,

5	Employee contributions/ Designated Roth contributions or insurance premiums
$

6	Net unrealized appreciation in employer's securities
$

7	Distribution code(s)

IRA/
SEP/
SIMPLE

8	Other
$

9a	Your percentage of total
	distribution		%

9b	Total employee contributions
$

10	Amount allocable to IRR within 5 years
$

11	1st year of desig. Roth contrib.

12	FATCA filing requirement

Account number (see instructions)

13	Date of payment