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Tax Year
Payer's Information
Payer's Address
Recipient's Information
Recipient’s Address
Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc.
FATCA Filing Requirement
$
$
2b. Taxable amount not determined
2b. Total distribution
$
$
$
$
$
1—Early distribution, no known exception
2—Early distribution, exception applies.
3—Disability.
4—Death.
5—Prohibited transaction.
6—Section 1035 exchange.
7—Normal distribution
8—Excess contributions plus earnings/excess deferrals (and/or earnings) taxable in 2022
9—Cost of current life insurance protection.
A—May be eligible for 10-year tax option.
B—Designated Roth account distribution.
C—Reportable death benefits under section 6050Y.
D—Annuity payments from nonqualified annuities and distributions from life insurance contracts that may be subject to tax under section 1411
E—Distributions under Employee Plans Compliance Resolution System (EPCRS).
F—Charitable gift annuity.
G—Direct rollover and direct payment.
H—Direct rollover of a designated Roth account distribution to a Roth IRA.
J—Early distribution from a Roth IRA.
K—Distribution of traditional IRA assets not having a readily available FMV.
M—Qualified plan loan offset.
N—Recharacterized IRA contribution made for 2022.
P—Excess contributions plus earnings/excess deferrals taxable in 2021.
Q—Qualified distribution from a Roth IRA.
R—Recharacterized IRA contribution made for 2021.
S—Early distribution from a SIMPLE IRA in the first 2 years, no known exception.
T—Roth IRA distribution, exception applies
U—Dividends distributed from an ESOP under section 404(k).
W—Charges or payments for purchasing qualified long-term care insurance contracts under combined arrangements.
Check this box in the IRA/SEP/SIMPLE checkbox if the distribution is from a traditional IRA, SEP IRA, or SIMPLE IRA. Do not check the box for a distribution from a Roth IRA or for an IRA recharacterization
$
%
%
$
$
$
$
$
$
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