2010 Form 1099-R by qlc15660

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                  9898                       VOID            CORRECTED
 PAYER’S name, street address, city, state, and ZIP code                 1 Gross distribution         OMB No. 1545-0119            Distributions From
                                                                                                                                  Pensions, Annuities,
                                                                                                                                        Retirement or
                                                                         $
                                                                        2a Taxable amount
                                                                                                        2010                            Profit-Sharing
                                                                                                                                          Plans, IRAs,
                                                                                                                                            Insurance
                                                                         $                              Form   1099-R                  Contracts, etc.
                                                                        2b Taxable amount                       Total                              Copy A
                                                                           not determined                       distribution
                                                                                                                                                     For
 PAYER’S federal identification        RECIPIENT’S identification        3 Capital gain (included      4 Federal income tax             Internal Revenue
 number                                number                              in box 2a)                      withheld                       Service Center

                                                                         $                                                              File with Form 1096.
                                                                                                       $
 RECIPIENT’S name                                                        5 Employee contributions      6 Net unrealized
                                                                             /Designated Roth            appreciation in                     For Privacy Act
                                                                             contributions or            employer’s securities               and Paperwork
                                                                             insurance premiums
                                                                                                                                              Reduction Act
                                                                         $                             $                                     Notice, see the
 Street address (including apt. no.)                                     7 Distribution       IRA/     8 Other                                2010 General
                                                                           code(s)           SEP/                                           Instructions for
                                                                                            SIMPLE
                                                                                                       $                           %                 Certain
                                                                                                                                                Information
 City, state, and ZIP code                                              9a Your percentage of total   9b Total employee contributions
                                                                                                                                                   Returns.
                                                                           distribution         %      $
                                     1st year of desig. Roth contrib.   10 State tax withheld         11 State/Payer’s state no. 12 State distribution
                                                                         $                                                              $
                                                                         $                                                              $
 Account number (see instructions)                                      13 Local tax withheld         14 Name of locality               15 Local distribution
                                                                         $                                                              $
                                                                         $                                                              $
Form   1099-R                                        Cat. No. 14436Q                                    Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page                                 —       Do Not Cut or Separate Forms on This Page
                                             VOID            CORRECTED
 PAYER’S name, street address, city, state, and ZIP code                 1 Gross distribution         OMB No. 1545-0119             Distributions From
                                                                                                                                   Pensions, Annuities,
                                                                                                                                         Retirement or
                                                                         $
                                                                        2a Taxable amount
                                                                                                        2010                             Profit-Sharing
                                                                                                                                           Plans, IRAs,
                                                                                                                                             Insurance
                                                                         $                              Form   1099-R                   Contracts, etc.
                                                                        2b Taxable amount                       Total                               Copy 1
                                                                           not determined                       distribution
                                                                                                                                                      For
 PAYER’S federal identification        RECIPIENT’S identification        3 Capital gain (included      4 Federal income tax                   State, City,
 number                                number                              in box 2a)                      withheld
                                                                                                                                                 or Local
                                                                                                                                         Tax Department
                                                                         $                             $
 RECIPIENT’S name                                                        5 Employee contributions      6 Net unrealized
                                                                             /Designated Roth            appreciation in
                                                                             contributions or            employer’s securities
                                                                             insurance premiums
                                                                         $                             $
 Street address (including apt. no.)                                     7 Distribution       IRA/     8 Other
                                                                           code(s)           SEP/
                                                                                            SIMPLE
                                                                                                       $                           %
 City, state, and ZIP code                                              9a Your percentage of total   9b Total employee contributions
                                                                           distribution         %      $
                                     1st year of desig. Roth contrib.   10 State tax withheld         11 State/Payer’s state no. 12 State distribution
                                                                         $                                                              $
                                                                         $                                                              $
 Account number (see instructions)                                      13 Local tax withheld         14 Name of locality               15 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            Distributions From
                                                                                                                                  Pensions, Annuities,
                                                                                                                                        Retirement or
                                                                         $
                                                                        2a Taxable amount
                                                                                                        2010                            Profit-Sharing
                                                                                                                                          Plans, IRAs,
                                                                                                                                            Insurance
                                                                         $                              Form   1099-R                  Contracts, etc.
                                                                        2b Taxable amount                       Total                              Copy B
                                                                           not determined                       distribution                   Report this
 PAYER’S federal identification        RECIPIENT’S identification        3 Capital gain (included      4 Federal income tax              income on your
 number                                number                              in box 2a)                      withheld                            federal tax
                                                                                                                                             return. If this
                                                                                                                                              form shows
                                                                         $                             $                                  federal income
 RECIPIENT’S name                                                        5 Employee contributions      6 Net unrealized                    tax withheld in
                                                                             /Designated Roth            appreciation in
                                                                             contributions or            employer’s securities               box 4, attach
                                                                             insurance premiums                                               this copy to
                                                                         $                             $                                      your return.
 Street address (including apt. no.)                                     7 Distribution       IRA/     8 Other
                                                                           code(s)           SEP/                                        This information is
                                                                                            SIMPLE
                                                                                                                                         being furnished to
                                                                                                       $                           %
                                                                                                                                                 the Internal
 City, state, and ZIP code                                              9a Your percentage of total   9b Total employee contributions     Revenue Service.
                                                                           distribution         %      $
                                     1st year of desig. Roth contrib.   10 State tax withheld         11 State/Payer’s state no. 12 State distribution
                                                                         $                                                              $
                                                                         $                                                              $
 Account number (see instructions)                                      13 Local tax withheld         14 Name of locality               15 Local distribution
                                                                         $                                                              $
                                                                         $                                                              $
Form   1099-R                                                                                           Department of the Treasury - Internal Revenue Service
Instructions for Recipient                                             Account number. May show an account or other unique number
Generally, distributions from pensions, annuities, profit-sharing      the payer assigned to distinguish your account.
and retirement plans (including section 457 state and local            Box 1. Shows the total amount you received this year. The
government plans), IRAs, insurance contracts, etc., are reported       amount may have been a direct rollover, a transfer or conversion
to recipients on Form 1099-R.                                          to a Roth IRA, a recharacterized IRA contribution; or you may
Qualified plans. If your annuity starting date is after 1997, you      have received it as periodic payments, as nonperiodic payments,
must use the simplified method to figure your taxable amount if        or as a total distribution. Report the amount on Form 1040 or
your payer did not show the taxable amount in box 2a. See the          1040A on the line for “IRA distributions” or “Pensions and
instructions for Form 1040 or 1040A.                                   annuities” (or the line for “Taxable amount”), and on Form 8606,
IRAs. For distributions from a traditional individual retirement       as applicable. However, if this is a lump-sum distribution, see
arrangement (IRA), simplified employee pension (SEP), or savings       Form 4972. If you have not reached minimum retirement age,
incentive match plan for employees (SIMPLE), generally the payer       report your disability payments on the line for “Wages, salaries,
is not required to compute the taxable amount. See the Form            tips, etc.” on your tax return. Also report on that line permissible
1040 or 1040A instructions to determine the taxable amount. If         withdrawals from eligible automatic contribution arrangements
you are at least age 70½, you must take minimum distributions          and corrective distributions of excess deferrals, excess
from your IRA (other than a Roth IRA). If you do not, you may be       contributions, or excess aggregate contributions except if you are
subject to a 50% excise tax on the amount that should have been        self-employed.
distributed. See Pub. 590 for more information on IRAs.                   If a life insurance, annuity, qualified long-term care, or
Roth IRAs. For distributions from a Roth IRA, generally the payer      endowment contract was transferred tax free to another trustee or
is not required to compute the taxable amount. You must                contract issuer, an amount will be shown in this box and Code 6
compute any taxable amount on Form 8606. An amount shown in            will be shown in box 7. If a charge or payment was made against
box 2a may be taxable earnings on an excess contribution. If you       the cash value of an annuity contract or the cash surrender value
converted or rolled over amounts to a Roth IRA from an eligible        of a life insurance contract for the purchase of qualified long-term
retirement plan in 2010, you generally include one half of the         care insurance, an amount will be shown in this box and Code W
taxable amount in income in 2011 and the other half in 2012. See       will be shown in box 7. You need not report these amounts on
Form 8606.                                                             your tax return.
Loans treated as distributions. If you borrow money from a             Box 2a. This part of the distribution is generally taxable. If there is
qualified plan, section 403(b) plan, or government plan, you may       no entry in this box, the payer may not have all the facts needed
have to treat the loan as a distribution and include all or part of    to figure the taxable amount. In that case, the first box in box 2b
the amount borrowed in your income. There are exceptions to this       should be checked. You may want to get one of the free
rule. If your loan is taxable, Code L will be shown in box 7. See      publications from the IRS to help you figure the taxable amount.
Pub. 575.                                                              See Additional information on the back of Copy 2. For an IRA
Recipient's identification number. For your protection, this form      distribution, see IRAs and Roth IRAs above. For a direct rollover,
may show only the last four digits of your social security number      other than from a qualified plan to a Roth IRA, zero should be
(SSN), individual taxpayer identification number (ITIN), or adoption   shown, and you must enter zero (-0-) on the “Taxable amount”
taxpayer identification number (ATIN). However, the issuer has         line of your tax return.
reported your complete identification number to the IRS, and,
where applicable, to state and/or local governments.                                                    (Continued on the back of Copy C.)
                                                              CORRECTED (if checked)
 PAYER’S name, street address, city, state, and ZIP code                      1 Gross distribution       OMB No. 1545-0119             Distributions From
                                                                                                                                      Pensions, Annuities,
                                                                                                                                            Retirement or
                                                                              $
                                                                          2a Taxable amount
                                                                                                           2010                             Profit-Sharing
                                                                                                                                              Plans, IRAs,
                                                                                                                                                Insurance
                                                                              $                            Form   1099-R                   Contracts, etc.
                                                                          2b Taxable amount                        Total                             Copy C
                                                                             not determined                        distribution
                                                                                                                                               For Recipient's
 PAYER’S federal identification        RECIPIENT’S identification             3 Capital gain (included    4 Federal income tax                       Records
 number                                number                                   in box 2a)                    withheld


                                                                              $                           $
 RECIPIENT’S name                                                             5 Employee contributions    6 Net unrealized
                                                                                  /Designated Roth          appreciation in
                                                                                  contributions or          employer’s securities
                                                                                  insurance premiums
                                                                              $                           $
 Street address (including apt. no.)                                          7 Distribution      IRA/    8 Other
                                                                                code(s)          SEP/                                       This information is
                                                                                                SIMPLE
                                                                                                                                            being furnished to
                                                                                                          $                           %
                                                                                                                                                    the Internal
 City, state, and ZIP code                                                9a Your percentage of total    9b Total employee contributions
                                                                                                                                             Revenue Service.
                                                                             distribution         %       $
                                     1st year of desig. Roth contrib.     10 State tax withheld          11 State/Payer’s state no. 12 State distribution
                                                                              $                                                            $
                                                                              $                                                            $
 Account number (see instructions)                                        13 Local tax withheld          14 Name of locality               15 Local distribution
                                                                              $                                                            $
                                                                              $                                                            $
Form   1099-R                                       (keep for your records)                                Department of the Treasury - Internal Revenue Service
Instructions for Recipient (Continued)
  If this is a total distribution from a qualified plan and you were born   Box 6. If you received a lump-sum distribution from a qualified plan
before January 2, 1936 (or you are the beneficiary of someone born          that includes securities of the employer’s company, the net unrealized
before January 2, 1936), you may be eligible for the 10-year tax            appreciation (NUA) (any increase in value of such securities while in
option. See the Form 4972 instructions for more information.                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 the
Box 2b. If the first box is checked, the payer was unable to determine      Form 4972 instructions. If you did not receive a lump-sum distribution,
the taxable amount, and box 2a should be blank. If the second box is        the amount shown is the NUA attributable to employee contributions,
checked, the distribution was a total distribution that closed out your     which is not taxed until you sell the securities.
account. If you are an eligible retired public safety officer who elected
                                                                            Box 7. The following codes identify the distribution you received. For
to exclude from income distributions from your eligible plan used to        more information on these distributions, see the instructions for your
purchase certain insurance premiums, the amount shown in box 2a             tax return. Also, certain distributions may be subject to an additional
has not been reduced by the exclusion amount. See the instructions          10% tax. See the instructions for Forms 5329 and 8606.
for Form 1040 or Form 1040A for more information.
                                                                            1—Early distribution, no known exception (in most cases, under age
Box 3. If you received a lump-sum distribution from a qualified plan          59½).
and were born before January 2, 1936 (or you are the beneficiary of         2—Early distribution, exception applies (under age 59½).
someone born before January 2, 1936), you may be able to elect to           3—Disability.
treat this amount as a capital gain on Form 4972 (not on Schedule D         4—Death.
(Form 1040)). See the Form 4972 instructions. For a charitable gift         5—Prohibited transaction.
annuity, report as a long-term capital gain on Schedule D.                  6—Section 1035 exchange (a tax-free exchange of life insurance,
Box 4. Shows federal income tax withheld. Include this amount on              annuity, qualified long-term care insurance, or endowment
                                                                              contracts).
your income tax return as tax withheld, and if box 4 shows an amount
                                                                            7—Normal distribution.
(other than zero), attach Copy B to your return. Generally, if you will
                                                                            8—Excess contributions plus earnings/excess deferrals (and/or
receive payments next year that are not eligible rollover distributions,
                                                                              earnings) taxable in 2010.
you can change your withholding or elect not to have income tax
                                                                            9—Cost of current life insurance protection.
withheld by giving the payer Form W-4P.                                     A—May be eligible for 10-year tax option (see Form 4972).
Box 5. Generally, this shows the employee’s investment in the               B—Designated Roth account distribution.
contract (after-tax contributions), if any, recovered tax free this year;   D—Excess contributions plus earnings/excess deferrals taxable in
the portion that is your basis in a designated Roth account; the part of      2008.
premiums paid on commercial annuities or insurance contracts                                                    (Continued on the back of Copy 2.)
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 the box next to box
10.
                                                             CORRECTED (if checked)
 PAYER’S name, street address, city, state, and ZIP code                 1 Gross distribution         OMB No. 1545-0119             Distributions From
                                                                                                                                   Pensions, Annuities,
                                                                                                                                         Retirement or
                                                                         $
                                                                        2a Taxable amount
                                                                                                        2010                             Profit-Sharing
                                                                                                                                           Plans, IRAs,
                                                                                                                                             Insurance
                                                                         $                              Form   1099-R                   Contracts, etc.
                                                                        2b Taxable amount                       Total                               Copy 2
                                                                           not determined                       distribution
                                                                                                                                              File this copy
 PAYER’S federal identification        RECIPIENT’S identification        3 Capital gain (included      4 Federal income tax                 with your state,
 number                                number                              in box 2a)                      withheld                             city, or local
                                                                                                                                                 income tax
                                                                         $                             $                                       return, when
                                                                                                                                                    required.
 RECIPIENT’S name                                                        5 Employee contributions      6 Net unrealized
                                                                             /Designated Roth            appreciation in
                                                                             contributions or            employer’s securities
                                                                             insurance premiums
                                                                         $                             $
 Street address (including apt. no.)                                     7 Distribution       IRA/     8 Other
                                                                           code(s)           SEP/
                                                                                            SIMPLE
                                                                                                       $                           %
 City, state, and ZIP code                                              9a Your percentage of total   9b Total employee contributions
                                                                           distribution         %      $
                                     1st year of desig. Roth contrib.   10 State tax withheld         11 State/Payer’s state no. 12 State distribution
                                                                         $                                                              $
                                                                         $                                                              $
 Account number (see instructions)                                      13 Local tax withheld         14 Name of locality               15 Local distribution
                                                                         $                                                              $
                                                                         $                                                              $
Form   1099-R                                                                                           Department of the Treasury - Internal Revenue Service
Instructions for Recipient (Continued)
E—Distributions under Employee Plans Compliance Resolution            than one person, the percentage of the annuity contract
  System (EPCRS).                                                     distributed to you is also shown. You will need this information if
F—Charitable gift annuity.                                            you use the 10-year tax option (Form 4972). If charges were made
                                                                      for qualified long-term insurance contracts under combined
G—Direct rollover of a distribution (other than a designated Roth
                                                                      arrangements, the amount of the reduction in the investment in
  account distribution) to a qualified plan, a section 403(b) plan,
                                                                      the annuity or life insurance contract is reported here.
  a governmental section 457(b) plan, or an IRA.
                                                                      Box 9a. If a total distribution was made to more than one person,
H—Direct rollover of a designated Roth account distribution to a
                                                                      the percentage you received is shown.
  Roth IRA.
                                                                      Box 9b. For a life annuity from a qualified plan or from a section
J—Early distribution from a Roth IRA, no known exception (in
                                                                      403(b) plan (with after-tax contributions), an amount may be
  most cases, under age 59½).
                                                                      shown for the employee’s total investment in the contract. It is
L—Loans treated as distributions.                                     used to compute the taxable part of the distribution. See Pub.
N—Recharacterized IRA contribution made for 2010 and                  575.
  recharacterized in 2010.                                            Boxes 10–15. If state or local income tax was withheld from the
P—Excess contributions plus earnings/excess deferrals taxable in      distribution, boxes 12 and 15 may show the part of the
  2009.                                                               distribution subject to state and/or local tax.
Q—Qualified distribution from a Roth IRA.
R—Recharacterized IRA contribution made for 2009 and                  Additional information. You may want to see:
  recharacterized in 2010.                                            Form W-4P, Withholding Certificate for Pension or Annuity
S—Early distribution from a SIMPLE IRA in first 2 years, no known     Payments,
  exception (under age 59½).                                          Form 4972, Tax on Lump-Sum Distributions,
T—Roth IRA distribution, exception applies.                           Form 5329, Additional Taxes on Qualified Plans (Including IRAs)
U—Dividend distribution from ESOP under sec. 404(k).                  and Other Tax-Favored Accounts,
                                                                      Form 8606, Nondeductible IRAs,
      Note. This distribution is not eligible for rollover.
                                                                      Pub. 560, Retirement Plans for Small Business (SEP, SIMPLE,
W—Charges or payments for purchasing qualified long-term care         and Qualified Plans),
     insurance contracts under combined arrangements.
                                                                      Pub. 571, Tax-Sheltered Annuity Plans (403(b) Plans),
  If the IRA/SEP/SIMPLE box is checked, you have received a
traditional IRA, SEP, or SIMPLE distribution.                         Pub. 575, Pension and Annuity Income,
Box 8. If you received an annuity contract as part of a               Pub. 590, Individual Retirement Arrangements (IRAs),
distribution, the value of the contract is shown. It is not taxable   Pub. 721, Tax Guide to U.S. Civil Service Retirement Benefits,
when you receive it and should not be included in boxes 1 and 2a.     Pub. 939, General Rule for Pensions and Annuities,
When you receive periodic payments from the annuity contract,         Pub. 969, Health Savings Accounts and Other Tax-Favored
they are taxable at that time. If the distribution is made to more    Health Plans.
                                             VOID            CORRECTED
 PAYER’S name, street address, city, state, and ZIP code                 1 Gross distribution         OMB No. 1545-0119             Distributions From
                                                                                                                                   Pensions, Annuities,
                                                                                                                                         Retirement or
                                                                         $
                                                                        2a Taxable amount
                                                                                                        2010                             Profit-Sharing
                                                                                                                                           Plans, IRAs,
                                                                                                                                             Insurance
                                                                         $                              Form   1099-R                   Contracts, etc.
                                                                        2b Taxable amount                       Total                              Copy D
                                                                           not determined                       distribution
                                                                                                                                                 For Payer
 PAYER’S federal identification        RECIPIENT’S identification        3 Capital gain (included      4 Federal income tax
 number                                number                              in box 2a)                      withheld


                                                                         $                             $
 RECIPIENT’S name                                                        5 Employee contributions      6 Net unrealized
                                                                             /Designated Roth            appreciation in                     For Privacy Act
                                                                             contributions or            employer’s securities               and Paperwork
                                                                             insurance premiums
                                                                                                                                              Reduction Act
                                                                         $                             $                                     Notice, see the
 Street address (including apt. no.)                                     7 Distribution       IRA/     8 Other                                2010 General
                                                                           code(s)           SEP/                                           Instructions for
                                                                                            SIMPLE
                                                                                                       $                           %                 Certain
                                                                                                                                                Information
 City, state, and ZIP code                                              9a Your percentage of total   9b Total employee contributions              Returns.
                                                                           distribution         %      $
                                     1st year of desig. Roth contrib.   10 State tax withheld         11 State/Payer’s state no. 12 State distribution
                                                                         $                                                              $
                                                                         $                                                              $
 Account number (see instructions)                                      13 Local tax withheld         14 Name of locality               15 Local distribution
                                                                         $                                                              $
                                                                         $                                                              $
Form   1099-R                                                                                           Department of the Treasury - Internal Revenue Service
Instructions for Payer
We provide general and specific form                 File Copy A of this form with the IRS by
instructions as separate products. The            February 28, 2011. If you file electronically, the
products you should use to complete Form          due date is March 31, 2011. To file
1099-R are the 2010 General Instructions for      electronically, you must have software that
Certain Information Returns and the 2010          generates a file according to the specifications
Instructions for Forms 1099-R and 5498. A         in Pub. 1220, Specifications for Filing Forms
chart in the general instructions gives a quick   1098, 1099, 3921, 3922, 5498, 8935, and
guide to which form must be filed to report a     W-2G Electronically. IRS does not provide a
particular payment. To order these instructions   fill-in form option.
and additional forms, visit the IRS website at    Need help? If you have questions about
www.irs.gov or call 1-800-TAX-FORM                reporting on Form 1099-R, call the information
(1-800-829-3676).                                 reporting customer service site toll free at
Caution: Because paper forms are scanned          1-866-455-7438 or 304-263-8700 (not toll
during processing, you cannot file with the IRS   free). For TTY/TDD equipment, call
Forms 1096, 1098, 1099, 3921, 3922, or 5498       304-579-4827 (not toll free). The hours of
that you print from the IRS website.              operation are Monday through Friday from
                                                  8:30 a.m. to 4:30 p.m., Eastern time.
Due dates. Furnish Copies B, C, and 2 of this
form to the recipient by January 31, 2011.

								
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