Form 1099-R Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc. 2021 Form 1099-R Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc. 2021 Summary: This is an example of Form 1099-R (2019) with information completed per the text. The line items are completed as follows: "PAYER'S name, street address, city, state, and ZIP code" field contains: Crabtree Corporation Employees' Pension Plan1111 Main StreetAnytown, Texas 75000 "PAYER'S federal identification number" field contains 10-0000000 "RECIPIENT'S identification number" field contains 002-00-XXXX "RECIPIENT'S name" field contains Robert C. Smith "RECIPIENT'S identification number" field contains 002-00-XXXX "Street address (including apartment number)" field contains 911 Mill Way "City, state, and ZIP code" field contains Anytown, Texas 75000 "1. Gross distribution" field contains $175000.00 "2a. Taxable amount" field contains $150000.00 "2b. Total distribution" checkbox checked "3. Capital gain (included in box 2a)" field contains $10000.00 "4. Federal income tax withheld" field contains $30000.00 "5. Employee contributions/Designated Roth contributions or insurance premiums" field contains $25000.00 "7. Distribution code(s)" field contains 7A
