ri CORRECTED (if checked)

ri CORRECTED (if checked) PAYERS name. street address. city or town. state or province. country. ZIP or foreign postal code. and phone no. 1 Gross distribution $ 2a Taxable amount OMB No. 1515.0119 2018 Form 1099-R Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc. 2b Taxable amount not determined K Total distribution E PAYER'S TIN RECIPIENT'S TIN 3 Capital gain (Included in box 2a) 4 Federal income tax withheld RECIPIENTS name Street address Oncluding 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 tst year of desig. Roth contrb. FATCA filing requrement 0 Date of payment 15 Local tax withheld $ $ wenvirs.gov/fomi1099R 5 Employee contributions/ Designated Roth contributions or insurance premiums 6 Net unrealized appreciation in employer's securities 7 Distribution code(s) IRA/ SEP/ SIMPLE 0 9a Your percentage of total distribution qy 12 State tax withheld $ 8 Other $ 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 IRS. 14 State distribution $ $ 17 Local distribution $ Department of the Treasisy - Internal Revenue Service EFTA01222606