10 DETACH BEFORE MAILING MANUFACTURED ON OCR LASER BOND PAPER USING HEAT RESISTANT INKS 5167 RECIPIENT'S name, street address, city or town, state or province, country, and ZIP or foreign postal code Form 1099-PATR Taxable Distributions Received From Cooperatives Copy B For Recipient Department of the Treasury - Internal Revenue Service This is important tax information and is being furnished to the IRS. If you are required negligence penalty or other sanction may be imposed on you if this income is taxable and the IRS determines that it has not been reported. OMB No. 1545-0118 For calendar year CORRECTED (if checked) PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no. PAYER’S TIN RECIPIENT’S TIN Account number (see instructions) 1 Patronage dividends 2 Nonpatronage distributions 3 Per-unit retain allocations 4 Federal income tax withheld 5 6 Section 199A(g) deduction 7 (Section 199A(b)(7)) 8 Section 199A(a) qual. items 9 Section 199A(a) SSTB items 10 Investment credit 11 Work opportunity credit 12 Other credits and deductions $ $ $ $ $ $ $ $ $ $ $ $ 13 Form 1099-PATR (keep for your records) www.irs.gov/Form1099PATR (Rev. April 2025) (Rev. 4-2025) RECIPIENT'S name, street address, city or town, state or province, country, and ZIP or foreign postal code Form 1099-PATR Taxable Distributions Received From Cooperatives Copy B For Recipient Department of the Treasury - Internal Revenue Service This is important tax information and is being furnished to the IRS. If you are required negligence penalty or other sanction may be imposed on you if this income is taxable and the IRS determines that it has not been reported. OMB No. 1545-0118 For calendar year CORRECTED (if checked) PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no. PAYER’S TIN RECIPIENT’S TIN Account number (see instructions) 1 Patronage dividends 2 Nonpatronage distributions 3 Per-unit retain allocations 4 Federal income tax withheld 5 6 Section 199A(g) deduction 7 (Section 199A(b)(7)) 8 Section 199A(a) qual. items 9 Section 199A(a) SSTB items 10 Investment credit 11 Work opportunity credit 12 Other credits and deductions $ $ $ $ $ $ $ $ $ $ $ $ 13 Form 1099-PATR (keep for your records) www.irs.gov/Form1099PATR (Rev. April 2025) (Rev. 4-2025) RECIPIENT'S name, street address, city or town, state or province, country, and ZIP or foreign postal code Form 1099-PATR Taxable Distributions Received From Cooperatives Copy B For Recipient Department of the Treasury - Internal Revenue Service This is important tax information and is being furnished to the IRS. If you are required negligence penalty or other sanction may be imposed on you if this income is taxable and the IRS determines that it has not been reported. OMB No. 1545-0118 For calendar year CORRECTED (if checked) PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no. PAYER’S TIN RECIPIENT’S TIN Account number (see instructions) 1 Patronage dividends 2 Nonpatronage distributions 3 Per-unit retain allocations 4 Federal income tax withheld 5 6 Section 199A(g) deduction 7 (Section 199A(b)(7)) 8 Section 199A(a) qual. items 9 Section 199A(a) SSTB items 10 Investment credit 11 Work opportunity credit 12 Other credits and deductions $ $ $ $ $ $ $ $ $ $ $ $ 13 Form 1099-PATR (keep for your records) www.irs.gov/Form1099PATR (Rev. April 2025) (Rev. 4-2025) 1099-PATR (PATRONAGE) Sheets per pack 25 50 500 FORM DESCRIPTION N/A 516650 N/A 1099-PATR Federal Copy A – 1 Sheet Equals 3 Forms N/A 516750 N/A 1099-PATR Recipient Copy B – 1 Sheet Equals 3 Forms 514025 514050 5140B 1099-R Federal Copy A – 1 Sheet Equals 2 Forms 514125 514150 5141B 1099-R Recipient Copy B – 1 Sheet Equals 2 Forms 514225 514250 5142B 1099-R Recipient Copy C – 1 Sheet Equals 2 Forms 514325 514350 5143B 1099-R State and/or File Copy – 1 Sheet Equals 2 Forms Required Envelope: 77771 or 77772 1099-R (RETIREMENT) 1099 PRE-PRINTED FORMS Required Envelope: DW19W or DW19WS 5166 5140 DETACH BEFORE MAILING MANUFACTURED ON OCR LASER BOND PAPER USING HEAT RESISTANT INKS 5143 RECIPIENT’S name, street address, city or town, state or province, country and ZIP or foreign postal code Form 1099-R 2025 Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc. Department of the Treasury - Internal Revenue Service OMB No. 1545-0119 CORRECTED (if checked) PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no. PAYER’S TIN RECIPIENT’S TIN Account number (see instructions) 1 Gross distribution 2a Taxable amount 2b Taxable amount not determined Total distribution 3 Capital gain (included in box 2a) 4 Federal income tax withheld 5 Employee contributions/ Designated Roth contributions or insurance premiums 6 Net unrealized appreciation in employer’s securities 7 Distribution code(s) IRA/ SEP/ SIMPLE 8 Other % 9a Your percentage of total distribution % 9b Total employee contributions 10 Amount allocable to IRR within 5 years 11 1st year of desig. Roth contrib. 12 requirement 13 Date of payment 14 State tax withheld 15 State/Payer’s state no. 16 State distribution 17 Local tax withheld 18 Name of locality 19 Local distribution Form 1099-R (keep for your records) www.irs.gov/Form1099R $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ RECIPIENT’S name, street address, city or town, state or province, country and ZIP or foreign postal code Form 1099-R 2025 Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc. Department of the Treasury - Internal Revenue Service OMB No. 1545-0119 CORRECTED (if checked) PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no. PAYER’S TIN RECIPIENT’S TIN Account number (see instructions) 1 Gross distribution 2a Taxable amount 2b Taxable amount not determined Total distribution 3 Capital gain (included in box 2a) 4 Federal income tax withheld 5 Employee contributions/ Designated Roth contributions or insurance premiums 6 Net unrealized appreciation in employer’s securities 7 Distribution code(s) IRA/ SEP/ SIMPLE 8 Other % 9a Your percentage of total distribution % 9b Total employee contributions 10 Amount allocable to IRR within 5 years 11 1st year of desig. Roth contrib. 12 requirement 13 Date of payment 14 State tax withheld 15 State/Payer’s state no. 16 State distribution 17 Local tax withheld 18 Name of locality 19 Local distribution Form 1099-R (keep for your records) www.irs.gov/Form1099R $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ To be Filed with Recipient’s State or Local Income Tax Return, or Copy 1 For State Tax Department To be Filed with Recipient’s State or Local Income Tax Return, or Copy 1 For State Tax Department Copy 2 Copy 2 VOID VOID DETACH BEFORE MAILING 9797 9797 9797 MANUFACTURED ON OCR LASER BOND PAPER USING HEAT RESISTANT INKS 41-0852411 Form 1099-PATR Taxable Distributions Received From Cooperatives Department of the Treasury - Internal Revenue Service OMB No. 1545-0118 For calendar year VOID CORRECTED PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no. PAYER’S TIN RECIPIENT’S TIN RECIPIENT’S name Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code Account number (see instructions) 2nd TIN not. 1 Patronage dividends 2 Nonpatronage distributions $ 3 Per-unit retain allocations 4 Federal income tax withheld 5 6 Section 199A(g) deduction 7 (Section 199A(b)(7)) 8 Section 199A(a) qual. items 9 Section 199A(a) SSTB items 10 Investment credit 11 Work opportunity credit 12 Other credits and deductions $ $ $ $ $ $ $ $ $ $ 13 Form 1099-PATR (Rev. April 2025) (Rev. 4-2025) www.irs.gov/Form1099PATR Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page $ Copy A For Internal Revenue Service Center Privacy Act, and Paperwork Reduction Act Notice, see the General Instructions for Certain Information Returns. www.irs.gov/Form1099 41-0852411 Form 1099-PATR Taxable Distributions Received From Cooperatives Department of the Treasury - Internal Revenue Service OMB No. 1545-0118 For calendar year VOID CORRECTED PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no. PAYER’S TIN RECIPIENT’S TIN RECIPIENT’S name Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code Account number (see instructions) 2nd TIN not. 1 Patronage dividends 2 Nonpatronage distributions $ 3 Per-unit retain allocations 4 Federal income tax withheld 5 6 Section 199A(g) deduction 7 (Section 199A(b)(7)) 8 Section 199A(a) qual. items 9 Section 199A(a) SSTB items 10 Investment credit 11 Work opportunity credit 12 Other credits and deductions $ $ $ $ $ $ $ $ $ $ 13 Form 1099-PATR (Rev. April 2025) (Rev. 4-2025) www.irs.gov/Form1099PATR $ Copy A For Internal Revenue Service Center Privacy Act, and Paperwork Reduction Act Notice, see the General Instructions for Certain Information Returns. www.irs.gov/Form1099 41-0852411 Form 1099-PATR Taxable Distributions Received From Cooperatives Department of the Treasury - Internal Revenue Service OMB No. 1545-0118 For calendar year VOID CORRECTED PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no. PAYER’S TIN RECIPIENT’S TIN RECIPIENT’S name Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code Account number (see instructions) 2nd TIN not. 1 Patronage dividends 2 Nonpatronage distributions $ 3 Per-unit retain allocations 4 Federal income tax withheld 5 6 Section 199A(g) deduction 7 (Section 199A(b)(7)) 8 Section 199A(a) qual. items 9 Section 199A(a) SSTB items 10 Investment credit 11 Work opportunity credit 12 Other credits and deductions $ $ $ $ $ $ $ $ $ $ 13 Form 1099-PATR (Rev. April 2025) (Rev. 4-2025) www.irs.gov/Form1099PATR Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page $ Copy A For Internal Revenue Service Center Privacy Act, and Paperwork Reduction Act Notice, see the General Instructions for Certain Information Returns. www.irs.gov/Form1099 5166 5167 DETACH BEFORE MAILING MANUFACTURED ON OCR LASER BOND PAPER USING HEAT RESISTANT INKS 5142 RECIPIENT’S name, street address, city or town, state or province, country and ZIP or foreign postal code Form 1099-R Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc. Department of the Treasury - Internal Revenue Service This information is being furnished to the IRS. OMB No. 1545-0119 CORRECTED (if checked) PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no. PAYER’S TIN RECIPIENT’S TIN Account number (see instructions) 1 Gross distribution $ 2a Taxable amount $ 2b Taxable amount not determined Total distribution 3 Capital gain (included in box 2a) $ 4 Federal income tax withheld $ 5 Employee contributions/ Designated Roth contributions or insurance premiums $ 6 Net unrealized appreciation in employer’s securities $ 7 Distribution code(s) IRA/ SEP/ SIMPLE 8 Other $ 9a Your percentage of total distribution 9b Total employee contributions $ 10 Amount allocable to IRR within 5 years $ requirement 13 Date of payment 14 State tax withheld $ $ 15 State/Payer’s state no. 16 State distribution $ $ 17 Local tax withheld $ $ 18 Name of locality 19 Local distribution $ $ Form 1099-R (keep for your records) www.irs.gov/Form1099R RECIPIENT’S name, street address, city or town, state or province, country and ZIP or foreign postal code Form 1099-R Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc. Department of the Treasury - Internal Revenue Service This information is being furnished to the IRS. OMB No. 1545-0119 CORRECTED (if checked) PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no. PAYER’S TIN RECIPIENT’S TIN Account number (see instructions) 1 Gross distribution $ 2a Taxable amount $ 2b Taxable amount not determined Total distribution 3 Capital gain (included in box 2a) $ 4 Federal income tax withheld $ 5 Employee contributions/ Designated Roth contributions or insurance premiums $ 6 Net unrealized appreciation in employer’s securities $ 7 Distribution code(s) IRA/ SEP/ SIMPLE 8 Other $ 9a Your percentage of total distribution 9b Total employee contributions $ 10 Amount allocable to IRR within 5 years $ 11 1st year of desig. Roth contrib. 12 11 1st year of desig. Roth contrib. 12 requirement 13 Date of payment 14 State tax withheld $ $ 15 State/Payer’s state no. 16 State distribution $ $ 17 Local tax withheld $ $ 18 Name of locality 19 Local distribution $ $ Form 1099-R (keep for your records) www.irs.gov/Form1099R % % % % LRC Copy C For Recipient's Copy C For Recipient's Records Records 2025 2025 5141 5142 5143 Individual Laser Packs DETACH BEFORE MAILING MANUFACTURED ON OCR LASER BOND PAPER USING HEAT RESISTANT INKS RECIPIENT’S name, street address, city or town, state or province, country and ZIP or foreign postal code LRB 5141 Form 1099-R Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc. 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. Department of the Treasury - Internal Revenue Service This information is being furnished to the IRS. OMB No. 1545-0119 CORRECTED (if checked) PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no. PAYER’S TIN RECIPIENT’S TIN Account number (see instructions) 1 Gross distribution $ 2a Taxable amount $ 2b Taxable amount not determined Total distribution 3 Capital gain (included in box 2a) $ 4 Federal income tax withheld $ 5 Employee contributions/ Designated Roth contributions or insurance premiums $ 6 Net unrealized appreciation in employer’s securities $ 7 Distribution code(s) IRA/ SEP/ SIMPLE 8 Other $ 9a Your percentage of total distribution 9b Total employee contributions $ 10 Amount allocable to IRR within 5 years $ 11 1st year of desig. Roth contrib. 12 requirement 13 Date of payment 14 State tax withheld $ $ 15 State/Payer’s state no. 16 State distribution $ $ 17 Local tax withheld $ $ 18 Name of locality 19 Local distribution $ $ Form 1099-R www.irs.gov/Form1099R RECIPIENT’S name, street address, city or town, state or province, country and ZIP or foreign postal code Form 1099-R Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc. 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. Department of the Treasury - Internal Revenue Service This information is being furnished to the IRS. OMB No. 1545-0119 CORRECTED (if checked) PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no. PAYER’S TIN RECIPIENT’S TIN Account number (see instructions) 1 Gross distribution $ 2a Taxable amount $ 2b Taxable amount not determined Total distribution 3 Capital gain (included in box 2a) $ 4 Federal income tax withheld $ 5 Employee contributions/ Designated Roth contributions or insurance premiums $ 6 Net unrealized appreciation in employer’s securities $ 7 Distribution code(s) IRA/ SEP/ SIMPLE 8 Other $ 9a Your percentage of total distribution 9b Total employee contributions $ 10 Amount allocable to IRR within 5 years $ 11 1st year of desig. Roth contrib. 12 requirement 13 Date of payment 14 State tax withheld $ $ 15 State/Payer’s state no. 16 State distribution $ $ 17 Local tax withheld $ $ 18 Name of locality 19 Local distribution $ $ Form 1099-R www.irs.gov/Form1099R % % % % 2025 2025 DETACH BEFORE MAILING 9898 9898 MANUFACTURED ON OCR LASER BOND PAPER USING HEAT RESISTANT INKS 5140 41-0852411 Form 1099-R 2025 Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc. Department of the Treasury - Internal Revenue Service Copy A For Internal Revenue Service Center OMB No. 1545-0119 VOID CORRECTED PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no. PAYER’S TIN RECIPIENT’S TIN RECIPIENT’S name Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code Account number (see instructions) 1 Gross distribution 2a $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Taxable amount 2b Taxable amount not determined Total distribution 3 Capital gain (included in box 2a) 4 Federal income tax withheld 5 Employee contributions/ Designated Roth contributions or insurance premiums 6 Net unrealized appreciation in employer’s securities 7 Distribution code(s) IRA/ SEP/ SIMPLE 8 Other 9a Your percentage of total distribution % 9b Total employee contributions 10 Amount allocable to IRR within 5 years 11 1st year of desig. Roth contrib. 12 requirement 13 Date of payment 14 State tax withheld 15 State/Payer’s state no. 16 State distribution 17 Local tax withheld 18 Name of locality 19 Local distribution Form 1099-R www.irs.gov/Form1099R Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page 41-0852411 Form 1099-R 2025 Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc. Department of the Treasury - Internal Revenue Service Copy A For Internal Revenue Service Center OMB No. 1545-0119 VOID CORRECTED PAYER’S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone no. PAYER’S TIN RECIPIENT’S TIN RECIPIENT’S name Street address (including apt. no.) City or town, state or province, country, and ZIP or foreign postal code Account number (see instructions) 1 Gross distribution 2a $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Taxable amount 2b Taxable amount not determined Total distribution 3 Capital gain (included in box 2a) 4 Federal income tax withheld 5 Employee contributions/ Designated Roth contributions or insurance premiums 6 Net unrealized appreciation in employer’s securities 7 Distribution code(s) IRA/ SEP/ SIMPLE 8 Other 9a Your percentage of total distribution % 9b Total employee contributions 10 Amount allocable to IRR within 5 years 11 1st year of desig. Roth contrib. 12 requirement 13 Date of payment 14 State tax withheld 15 State/Payer’s state no. 16 State distribution 17 Local tax withheld 18 Name of locality 19 Local distribution Form 1099-R www.irs.gov/Form1099R $ $ % Privacy Act, and Paperwork Reduction Act Notice, see the General Instructions for Certain Information Returns. www.irs.gov/Form1099 Privacy Act, and Paperwork Reduction Act Notice, see the General Instructions for Certain Information Returns. www.irs.gov/Form1099 % Catalog images may not reflect official IRS revisions at the time of publication. Final products will be in compliance with official IRS revisions.
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