Version of Sample Template Evisions

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					 Copy 2 -- File this copy                                  Distributions From                             OMB No.         Copy 2 -- File this copy                                  Distributions From                              OMB No.
                                                           Pensions, Annuities,                          1545-0119                                                                                                                 1545-0119
 with your state, city, or                                                                                                with your state, city, or                                 Pensions, Annuities,
 local income tax return,
 when required.
                                                           Retirement or Profit-
                                                           Sharing Plans, IRAs,
                                                                                                      2011 Form
                                                                                                                          local income tax return,
                                                                                                                          when required.
                                                                                                                                                                                    Retirement or Profit-
                                                                                                                                                                                    Sharing Plans, IRAs,
                                                                                                                                                                                                                                2011 Form
                                                           Insurance Contracts, etc.                      1099-R                                                                    Insurance Contracts, etc.                       1099-R

 Account number (see instructions)                                                         CORRECTED                      Account number (see instructions)                                                           CORRECTED
                                        1234567890                                         (if checked)                                                          1234567890                                           (if checked)
 PAYER'S name, street address, city, state, and ZIP code                                                                  PAYER'S name, street address, city, state, and ZIP code
    Evisions Institute of Technology                                                                                          Evisions Institute of Technology
    410 Exchange                                                                                                              410 Exchange
    Irvine, CA 92602                                                                                                          Irvine, CA 92602
 PAYER'S federal identification number                      RECIPIENT'S identification number                             PAYER'S federal identification number                      RECIPIENT'S identification number
    99-123456                                                    123456789                                                    99-123456                                                      123456789
 RECIPIENT'S name, street address (including apt. no.), city, state, and ZIP code                                         RECIPIENT'S name, street address (including apt. no.), city, state, and ZIP code
    Gerald Goodhart                                                                                                           Gerald Goodhart
    123 Any Street                                                                                                            123 Any Street
    Anytown, CA 12345                                                                                                         Anytown, CA 12345
1. Gross distribution                     2a Taxable amount                        2b Taxable amount
                                                                                      not determined
                                                                                                                 X       1. Gross distribution                      2a Taxable amount                         2b Taxable amount
                                                                                                                                                                                                                 not determined
                                                                                                                                                                                                                                           X
$   999999999.99 $999999999.99                                                        Total distribution         X       $   999999999.99 $999999999.99                                                          Total distribution        X
3 Capital gain (included in               4 Federal income tax withheld          5 Employee contributions/Desig.         3 Capital gain (included in               4 Federal income tax withheld            5 Employee contributions/Desig.
                     box 2a)                                                       Roth contribs. / ins. premiums                              box 2a)                                                        Roth contribs. / ins. premiums
$    99999999.99 999999999.99
 6 Net unrealized appreciation in
                                          $                                    $         99999999.99                     $       99999999.99 $999999999.99 $ 99999999.99
                                         7 Distribution       IRA/SEP/   8 Other                                             6 Net unrealized appreciation in      7 Distribution       IRA/SEP/    8 Other
 employer's securities
                                                                                                          %                                                                                                                         %
                                         code(s)               SIMPLE                                                        employer's securities                 code(s)               SIMPLE

$     99999999.99                                    1          X        $   99999999.99                        12       $       99999999.99                                  1           X         $   99999999.99                       12
9a Your percentage           9b Total employee                    10 Amount allocable to         11 1st year of desig.   9a Your percentage           9b Total employee                      10 Amount allocable to         11 1st year of
   of total distribution     contributions                        IRR within 5 years             Roth contrib.              of total distribution     contributions                          IRR within 5 years             desig. Roth contrib.

 999.99                % $       99999999.99 $ 99999999.99 2001                                                           999.99                %     $    99999999.99                       $     99999999.99                     2001
$                                                                                 $                                      $                                                                                  $
$   99999999.99                               99-123456789 $ 99999999.99                                                 $    99999999.99                              99-123456789 $ 99999999.99
12 State tax withheld                     13 State/Payer's state no.             14 State distribution                   12 State tax withheld                     13 State/Payer's state no.              14 State distribution
15 Local tax withheld                     16 Name of locality                    17 Local distribution                   15 Local tax withheld                     16 Name of locality                     17 Local distribution
$   99999999.99                               CA                                 $    99999999.99                        $    99999999.99                              CA                                  $    99999999.99
$                                                                                $                                       $                                                                                  $
Form   1099-R              Department of the Treasury - Internal Revenue Service                         38-2099803      Form      1099-R           Department of the Treasury - Internal Revenue Service                          38-2099803




 Copy C -- For Recipient's                                 Distributions From                             OMB No.         Copy B -- Report this income                              Distributions From                              OMB No.
 Records                                                   Pensions, Annuities,                          1545-0119        on your federal tax return.                               Pensions, Annuities,                           1545-0119
 (keep for your records)
 This information is being furnished to the
                                                           Retirement or Profit-
                                                           Sharing Plans, IRAs,
                                                                                                      2011 Form
                                                                                                                          If this form shows federal
                                                                                                                          income tax withheld in Box 4,
                                                                                                                                                                                    Retirement or Profit-
                                                                                                                                                                                    Sharing Plans, IRAs,
                                                                                                                                                                                                                                2011 Form
 Internal Revenue Service.                                                                                1099-R                                                                                                                    1099-R
                                                           Insurance Contracts, etc.                                      attach this copy to your return.                          Insurance Contracts, etc.
 Account number (see instructions)                                                         CORRECTED                      Account number (see instructions)                                                           CORRECTED
                                        1234567890                                         (if checked)                                                          1234567890                                           (if checked)
 PAYER'S name, street address, city, state, and ZIP code                                                                  PAYER'S name, street address, city, state, and ZIP code
    Evisions Institute of Technology                                                                                          Evisions Institute of Technology
    410 Exchange                                                                                                              410 Exchange
    Irvine, CA 92602                                                                                                          Irvine, CA 92602
 PAYER'S federal identification number                      RECIPIENT'S identification number                             PAYER'S federal identification number                      RECIPIENT'S identification number
    99-123456                                                    123456789                                                    99-123456                                                      123456789
 RECIPIENT'S name, street address (including apt. no.), city, state, and ZIP code                                         RECIPIENT'S name, street address (including apt. no.), city, state, and ZIP code

    Gerald Goodhart                                                                                                           Gerald Goodhart
    123 Any Street                                                                                                            123 Any Street

    Anytown, CA 12345                                                                                                         Anytown, CA 12345
                                                                                                                                                                                                             2b Taxable amount
1. Gross distribution                      2a Taxable amount                       2b Taxable amount
                                                                                      not determined
                                                                                                                 X       1. Gross distribution                     2a Taxable amount
                                                                                                                                                                                                                not determined
                                                                                                                                                                                                                                           X
$   999999999.99 999999999.99             $                                           Total distribution         X       $   999999999.99 999999999.99             $                                            Total distribution         X
3 Capital gain (included in               4 Federal income tax withheld          5 Employee contributions/Desig.         3 Capital gain (included in               4 Federal income tax withheld            5 Employee contributions/Desig.
                     box 2a)                                                       Roth contribs. / ins. premiums                              box 2a)                                                        Roth contribs. / ins. premiums
$   99999999.99 $ 999999999.99 $ 99999999.99                                                                             $      99999999.99 $ 999999999.99 $ 99999999.99
 6 Net unrealized appreciation in         7 Distribution      IRA/SEP/                                                    6 Net unrealized appreciation in                             IRA/SEP/
                                                                         8 Other                          %                                                       7 Distribution                    8 Other                         %
 employer's securities                    code(s)              SIMPLE                                                     employer's securities                   code(s)               SIMPLE

$    99999999.99                                     1          X        $   99999999.99                        12       $      99999999.99                                   1          X          $   99999999.99                       12
9a Your percentage           9b Total employee                  10 Amount allocable to           11 1st year of desig.   9a Your percentage          9b Total employee                    10 Amount allocable to             11 1st year of desig.
   of total distribution     contributions                      IRR within 5 years               Roth contrib.              of total distribution    contributions                        IRR within 5 years                 Roth contrib.

 999.99                % $      99999999.99                     $   99999999.99 2001                                      999.99                %     $   99999999.99                    $       99999999.99                       2001
$                                                                                 $                                      $                                                                                 $

$   99999999.99                               99-123456789 1499999999.99
                                                           $                                                             $   99999999.99                               99-123456789 $ 99999999.99
12 State tax withheld                                        State distribution
                                          13 State/Payer's state no.                                                     12 State tax withheld                    13 State/Payer's state no.               14 State distribution
15 Local tax withheld                     16 Name of locality                    17 Local distribution                   15 Local tax withheld                    16 Name of locality                      17 Local distribution
$   99999999.99                               CA                                 $    99999999.99                        $   99999999.99                               CA                                  $   99999999.99
$                                                                                 $                                      $                                                                                 $
Form   1099-R              Department of the Treasury - Internal Revenue Service                         38-2099803      Form 1099-R Department of the Treasury - Internal Revenue Service                                         38-2099803
                                                                                                                         This information is being furnished to the Internal Revenue Service.
Evisions Institute of Technology
410 Exchange
Irvine, CA 92602




Gerald Goodhart
123 Any Street

Anytown, CA 12345

				
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