ri CORRECTED (if checked)

ri CORRECTED (if checked) PAYERS name. street address, city or town, state or province. country. and ZIP or foreign postal code 1 Gross distribution $ 2a Taxable amount $ 2b Taxable amount not determined p cMB No. 1545.0119 2017 Form 1099-R Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc. Total distribution E PAYER'S federal identification number RECIPIENTS identification number 3 Capital gain (Included in box 2a) 4 Federal income tax withheld RECIPIENT'S name Street address (Including apt. no.) City or town. state or province, country, and ZIP or foreign postal code 10 Amount allocable to IRR within 5 years $ Account number (see instructions) Form 1099-R 11 1 st year of desig. Roth contrib. FATCA filing requirement 0 vonwirs.gov/form1O99r 5 Employee contnbutions /Designated Ro h contributions or insurance premiums 6 Net unrealized appreciation in employers securities 7 Distribution code(s) IAN SEP/ SIMPLE 0 8 Other Sa Your percentage of total distribution 12 State tax Withheld $ 15 Local tax withheld $ $ 9b Total employee contributions $ 13 State/Payer's state no. 16 Name of locality 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. 14 State distribution $ $ 17 Local distribution $ $ Department of the Treasury - Internal Revenue Service EFTA01222605