Life Insurance Service
Resume:
CORRECTED (if checked)
PAYER'S name, street address, city, state, and ZIP code 1 Gross distribution OMB No. 1545-0119 JPMORGAN CHASE BANK NA TEFRA ACCT
BENEFIT PAYMENT SERVICES
P.O. BOX 6300
NEWARK, DE 19714-9807
Distributions From Pensions,
Annuities, Retirement or
Profit-Sharing Plans,IRAs,
Insurance Contracts, etc.
$5,580.12
2a Taxable amount 2017
$5,580.12 Form 1099-R
DFW INTERNATIONAL AIRPORT
BOARD RETIREMENT PLAN
Phone support: 1-877-***-****
2b Taxable amount not
determined
Copy B
Report this income
on your federal tax
return. If this form
shows federal income
tax withheld in
box 4, attach this
copy to your return.
This information
is being furnished to the
Internal Revenue Service.
Total distribution
3 Capital gain (included in box 2a) 4 Federal income tax withheld
$0.00
5 Employee contributions/Designated
Roth contributions or insurance
premiums
6 Net unrealized appreciation in employer's
securities
PAYER'S federal identification number RECIPIENT'S identification number 7 Distribution code(s) IRA / SEP /
SIMPLE
13-379****-**** 8 Other
7 %
RECIPIENT'S name, street address, city, state, and ZIP code 9a Your percentage of total distribution 9b Total employee contributions 000001 003390D71 3270 39
ELLISON, SANDRA
5616 BOCA RATON BLVD APT 238
FT. WORTH, TX 76112-1834
%
10 Amount allocable to IRR within 5
years
11 1st year of desig. Roth contrib.
12 State tax withheld 13 State/Payer's state no. 14 State distribution TX
Account number (see instructions)
003390D71256571 FATCA filing
requirement
15 Local tax withheld 16 Name of locality 17 Local distribution Form 1099-R Department of the Treasury-Internal Revenue Service CORRECTED (if checked)
PAYER'S name, street address, city, state, and ZIP code 1 Gross distribution OMB No. 1545-0119 JPMORGAN CHASE BANK NA TEFRA ACCT
BENEFIT PAYMENT SERVICES
P.O. BOX 6300
NEWARK, DE 19714-9807
Distributions From Pensions,
Annuities, Retirement or
Profit-Sharing Plans,IRAs,
Insurance Contracts, etc.
$5,580.12
2a Taxable amount 2017
$5,580.12 Form 1099-R
DFW INTERNATIONAL AIRPORT
BOARD RETIREMENT PLAN
Phone support: 1-877-***-****
2b Taxable amount not
determined
Copy C
For Recipient's
Records
This information is
being furnished to
the Internal
Revenue Service.
Total distribution
3 Capital gain (included in box 2a) 4 Federal income tax withheld
$0.00
5 Employee contributions/Designated
Roth contributions or insurance
premiums
6 Net unrealized appreciation in employer's
securities
PAYER'S federal identification number RECIPIENT'S identification number 7 Distribution code(s) IRA / SEP /
SIMPLE
13-379****-**** 8 Other
7 %
RECIPIENT'S name, street address, city, state, and ZIP code 9a Your percentage of total distribution 9b Total employee contributions 000001 003390D71 3270 39
ELLISON, SANDRA
5616 BOCA RATON BLVD APT 238
FT. WORTH, TX 76112-1834
%
10 Amount allocable to IRR within 5
years
11 1st year of desig. Roth contrib.
12 State tax withheld 13 State/Payer's state no. 14 State distribution TX
Account number (see instructions)
003390D71256571 FATCA filing
requirement
15 Local tax withheld 16 Name of locality 17 Local distribution Form 1099-R (keep for your records) Department of the Treasury-Internal Revenue Service CORRECTED (if checked)
PAYER'S name, street address, city, state, and ZIP code 1 Gross distribution OMB No. 1545-0119 JPMORGAN CHASE BANK NA TEFRA ACCT
BENEFIT PAYMENT SERVICES
P.O. BOX 6300
NEWARK, DE 19714-9807
Distributions From Pensions,
Annuities, Retirement or
Profit-Sharing Plans,IRAs,
Insurance Contracts, etc.
$5,580.12
2a Taxable amount 2017
$5,580.12 Form 1099-R
DFW INTERNATIONAL AIRPORT
BOARD RETIREMENT PLAN
Phone support: 1-877-***-****
2b Taxable amount not
determined
Copy 2
File this copy
with your state,
city, or local
income tax
return, when
required.
Total distribution
3 Capital gain (included in box 2a) 4 Federal income tax withheld
$0.00
5 Employee contributions/Designated
Roth contributions or insurance
premiums
6 Net unrealized appreciation in employer's
securities
PAYER'S federal identification number RECIPIENT'S identification number 7 Distribution code(s) IRA / SEP /
SIMPLE
13-379****-**** 8 Other
7 %
RECIPIENT'S name, street address, city, state, and ZIP code 9a Your percentage of total distribution 9b Total employee contributions 000001 003390D71 3270 39
ELLISON, SANDRA
5616 BOCA RATON BLVD APT 238
FT. WORTH, TX 76112-1834
%
10 Amount allocable to IRR within 5
years
11 1st year of desig. Roth contrib.
12 State tax withheld 13 State/Payer's state no. 14 State distribution TX
Account number (see instructions)
003390D71256571 FATCA filing
requirement
15 Local tax withheld 16 Name of locality 17 Local distribution Form 1099-R Department of the Treasury-Internal Revenue Service Page 1 of 2
1099-R Instructions for Recipient
Generally, distributions from pensions, annuities, profit-sharing and retirement plans (including section 457 state and local government plans), IRAs, insurance contracts, etc., are reported to recipients on Form 1099-R.
Qualified plans. If your annuity starting date is after 1997, you must use the simplified method to figure your taxable amount if your payer did not show the taxable amount in box 2a. See the instructions for Form 1040, 1040A, or 1040NR.
IRAs. For distributions from a traditional individual retirement arrangement (IRA), simplified employee pension (SEP), or savings incentive match plan for employees (SIMPLE), generally the payer is not required to compute the taxable amount. See the Form 1040, 1040A, or 1040NR instructions to determine the taxable amount. If you are at least age 70 1/2, you must take minimum distributions from your IRA (other than a Roth IRA). If you do not, you are subject to a 50% excise tax on the amount that should have been distributed. See Pub. 590-A and Pub. 590-B for more information on IRAs.
Roth IRAs. For distributions from a Roth IRA, generally the payer is not required to compute the taxable amount. You must compute any taxable amount on Form 8606. An amount shown in box 2a may be taxable earnings on an excess contribution. Loans treated as distributions. If you borrow money from a qualified plan, section 403(b) plan, or governmental section 457(b) plan, you may have to treat the loan as a distribution and include all or part of the amount borrowed in your income. There are exceptions to this rule. If your loan is taxable, Code L will be shown in box 7. See Pub. 575. Recipient's taxpayer identification number. For your protection, this form may show only the last four digits of your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN). However, the issuer has reported your complete identification number to the IRS. FATCA filing requirement. If the FATCA filing requirement box is checked, the payer is reporting on this Form 1099 to satisfy its chapter 4 account reporting requirement. You also may have a filing requirement. See the Instructions for Form 8938.
Account number. May show an account or other unique number the payer assigned to distinguish your account.
Box 1. Shows the total amount you received this year. The amount may have been a direct rollover, a transfer or conversion to a Roth IRA, a recharacterized IRA contribution; or you may have received it as periodic payments, as nonperiodic payments, or as a total distribution. Report the amount on Form 1040, 1040A, or 1040NR on the line for "IRA distributions" or "Pensions and annuities" (or the line for
"Taxable amount"), and on Form 8606, as applicable. However, if this is a lump-sum distribution, see Form 4972. If you have not reached minimum retirement age, report your disability payments on the line for "Wages, salaries, tips, etc." on your tax return. Also report on that line permissible withdrawals from eligible automatic contribution arrangements and corrective distributions of excess deferrals, excess contributions, or excess aggregate contributions except if the distribution is of designated Roth contributions or your after-tax contributions or if you are self-employed. If a life insurance, annuity, qualified long-term care, or endowment contract was transferred tax free to another trustee or contract issuer, an amount will be shown in this box and Code 6 will be shown in box 7. If a charge or payment was made against the cash value of an annuity contract or the cash surrender value of a life insurance contract for the purchase of qualified long-term care insurance, an amount will be shown in this box and Code W will be shown in box 7. You need not report these amounts on your tax return.
Box 2a. This part of the distribution is generally taxable. If there is no entry in this box, the payer may not have all the facts needed to figure the taxable amount. In that case, the first box in box 2b should be checked. You may want to get one of the free publications from the IRS to help you figure the taxable amount. See Additional information on the back of Copy 2. For an IRA distribution, see IRAs and Roth IRAs on this page. For a direct rollover, other than from a qualified plan to a Roth IRA, zero should be shown, and you must enter zero (-0-) on the "Taxable amount" line of your tax return. If you roll over a distribution (other than a distribution from a designated Roth account) from a qualified plan (including a governmental section 457(b) plan) or section 403(b) plan to a Roth IRA, you must include on the "Taxable amount" line of your tax return the amount shown in this box plus the amount in box 6, if any.
If this is a total distribution from a qualified plan and you were born before January 2, 1936 (or you are the beneficiary of someone born before January 2, 1936), you may be eligible for the 10-year tax option. See the Form 4972 instructions for more information. If you are an eligible retired public safety officer who elected to exclude from income distributions from your eligible plan used to pay certain insurance premiums, the amount shown in box 2a has not been reduced by the exclusion amount. See the instructions for Form 1040, 1040A, or 1040NR for more information.
Box 2b. If the first box is checked, the payer was unable to determine the taxable amount, and box 2a should be blank, except for an IRA. It is your responsibility to determine the taxable amount. If the second box is checked, the distribution was a total distribution that closed out your account. Box 3. If you received a lump-sum distribution from a qualified plan and were born before January 2, 1936 (or you are the beneficiary of someone born before January 2, 1936), you may be able to elect to treat this amount as a capital gain on Form 4972 (not on Schedule D (Form 1040)). See the Form 4972 instructions. For a charitable gift annuity, report as a long-term capital gain as explained in the Instructions for Form 8949.
Box 4. Shows federal income tax withheld. Include this amount on your income tax return as tax withheld, and if box 4 shows an amount (other than zero), attach Copy B to your return. Generally, if you will receive payments next year that are not eligible rollover distributions, you can change your withholding or elect not to have income tax withheld by giving the payer Form W-4P. Box 5. Generally, this shows the employee's investment in the contract (after-tax contributions), if any, recovered tax free this year; the portion that is your basis in a designated Roth account; the part of premiums paid on commercial annuities or insurance contracts recovered tax free; or the nontaxable part of a charitable gift annuity. This box does not show any IRA contributions. If the amount shown is your basis in a designated Roth account, the year you first made contributions to that account may be entered in box 11.
Box 6. If you received a lump-sum distribution from a qualified plan that includes securities of the employer's company, the net unrealized appreciation (NUA) (any increase in value of such securities while in the trust) is taxed only when you sell the securities unless you choose to include it in your gross income this year. See Pub. 575 and Form 4972. If you roll over the distribution to a Roth IRA, see the instructions for Box 2a. If the distribution was a direct rollover, the NUA is included in box 2a. If you did not receive a lump-sum distribution, the amount shown is the NUA attributable to employee contributions, which is not taxed until you sell the securities. Box 7. The following codes identify the distribution you received. For more information on these distributions, see the instructions for your tax return. Also, certain distributions may be subject to an additional 10% tax. See the Instructions for Form 5329. 1-Early distribution, no known exception (in most cases, under age 59 1/2). 2-Early distribution, exception applies (under age 59 1/2). 3-Disability. 4-Death. 5-Prohibited transaction. 6-Section 1035 exchange (a tax-free exchange of life insurance, annuity, qualified long-term care insurance, or endowment contracts). 7-Normal distribution. 8-Excess contributions plus earnings/excess deferrals (and/or earnings) taxable in 2017. 9-Cost of current life insurance protection. A-May be eligible for 10-year tax option (see Form 4972). B-Designated Roth account distribution. Note: If Code B is in box 7 and an amount is reported in box 10, see the Instructions for Form 5329. D-Annuity payments from nonqualified annuities 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 of a distribution to a qualified plan, a section 403(b) plan, a governmental section 457(b) plan, or an IRA. H-Direct rollover of a designated Roth account distribution to a Roth IRA. J-Early distribution from a Roth IRA, no known exception (in most cases, under age 59 1/2). K-Distribution of traditional IRA assets not
having a readily available FMV. L-Loans treated as distributions. N-Recharacterized IRA contribution made for 2017 and recharacterized in 2017. P-Excess contributions plus earnings/excess deferrals (and/or earnings) taxable in 2016. Q-Qualified distribution from a Roth IRA. R-Recharacterized IRA contribution made for 2016 and recharacterized in 2017. S-Early distribution from a SIMPLE IRA in first 2 years, no known exception (under age 59 1/2). T-Roth IRA distribution, exception applies. U-Dividend distribution from ESOP under section 404(k). Note: This distribution is not eligible for rollover. W-Charges or payments for purchasing qualified long-term care insurance contracts under combined arrangements. If the IRA/SEP/SIMPLE box is checked, you have received a traditional IRA, SEP, or SIMPLE distribution.
Box 8. If you received an annuity contract as part of a distribution, the value of the contract is shown. It is not taxable when you receive it and should not be included in boxes 1 and 2a. When you receive periodic payments from the annuity contract, they are taxable at that time. If the distribution is made to more than one person, the percentage of the annuity contract distributed to you is also shown. You will need this information if you use the 10-year tax option (Form 4972). If charges were made for qualified long-term care insurance contracts under combined arrangements, the amount of the reduction in the investment (but not below zero) in the annuity or life insurance contract is reported here. Box 9a. If a total distribution was made to more than one person, the percentage you received is shown. Box 9b. For a life annuity from a qualified plan or from a section 403(b) plan (with after-tax contributions), an amount may be shown for the employee's total investment in the contract. It is used to compute the taxable part of the distribution. See Pub. 575.
Box 10. If an amount is reported in this box, see the Instructions for Form 5329 and Pub. 575. Box 11. The 1st year you made a contribution to the designated Roth account reported on this form is shown in this box.
Boxes 12-17. If state or local income tax was withheld from the distribution, boxes 14 and 17 may show the part of the distribution subject to state and/or local tax. Future developments. For the latest information about developments related to Form 1099-R and its instructions, such as legislation enacted after they were published, go to www.irs.gov/form1099r. Additional information. You may want to see:
Form W-4P Pub. 575
Form 4972 Pub. 590-A
Form 5329 Pub. 590-B
Form 8606 Pub. 721
Pub. 560 Pub. 939
Pub. 571 Pub. 969
JPMORGAN CHASE BANK NA TEFRA ACCT
BENEFIT PAYMENT SERVICES
P.O. BOX 6300
NEWARK, DE 19714-9807
000001 003390D71 3270 39
ELLISON, SANDRA
5616 BOCA RATON BLVD APT 238
FT. WORTH, TX 76112-1834
Page 2 of 2
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