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Certain code(s) $ Department of the Treasury - Internal Revenue ServiceInformation www.irs.gov/Form1099R$ Returns. 9aYour percentage of total 9bTotal employee contributions being furnished to the IRS.Form1099-PATR LPC www.irs.gov/Form1099PATR 5168 Department of the Treasury - Internal Revenue Service Form1099-Q (Rev. 11-2019) LQC 5196 www.irs.gov/Form1099Q Department of the Treasury - Internal Revenue Service distribution %$10Amount allocable to IRR111st year of desig. 12 requirement$ 14State tax withheld 15State/Payers state no. $ 16State distributionwithin 5 years Roth contrib.$ VOID $ CORRECTED $ Distributions From PAYERS name, street address, city or town, state or province,1Gross distribution18Name of locality 19Local distributionAccount number (see instructions) 17Local tax withheld OMB No. 1545-0119 Pensions, Annuities,country, ZIP or foreign postal code, and telephone no.payment 13Date of$ $ $ Retirement or Required Envelope: Required Envelope: Form 1099-R (keep for your records) LRC/LR2 $ $ 2aTaxable amount 2022 Prot-Sharing Plans, $IRAs, Insurance www.irs.gov/Form1099R 5142 Department of the Treasury - Internal Revenue ServiceContracts, etc.Form 1099-R2bTaxable amountTotalCopy D APEX/TFP: DW19W or DW19WS APEX/TFP: DW19W or DW19WS PAYERS TIN RECIPIENTS TIN not determined 4 distributionFor Payer 3Capital gain (included inFederal income tax and/orbox 2a) withheld State, r City,l$ $ Tax LocatDepoartmenRECIPIENTS name, stret adres, city or town, state or province, country and ZIP or foreign postal code 5Employee contributions/ 6appreciation in For Privacy Act Designated RothNet unrealizedcontributions oremployers securities and Paperwork insurance premiums Reduction Act $ IRA/ $ 8Other Notice, see the 7DistributionSEP/2022 Generalcode(s) SIMPLE $ % Instructions forCertain 9aYour percentage of total 9bTotal employee contributions Information distribution %$ Returns.10Amount allocable to IRR111st year of desig. 12 requirement$ 14State tax withheld 15State/Payers state no. $ 16State distributionwithin 5 years Roth contrib.$ $ $Account number (see instructions) 13Date of17Local tax withheld 18Name of locality 19Local distributionpayment$ $$ $Form 1099-R LRD1 5143 www.irs.gov/Form1099R Department of the Treasury - Internal Revenue ServiceRequired Envelope:APEX: DWMR or DWMRSTFP: 77771 or 77772APEX - Sheets per packTFP - Forms per pack50s500s100s1000sFORM DESCRIPTIONLPAN/A5166N/A1099-PATR Federal Copy A1 Page Equals 3 FormsLPBN/A5167N/A1099-PATR Recipient Copy B1 Page Equals 3 FormsLPCN/A5168N/A1099-PATR Payer Copy C and/or State/Copy1 Page Equals 3 FormsLQAN/A5194N/A1099-Q Federal Copy A1 Page Equals 3 FormsLQBN/A5195N/A1099-Q Recipient Copy B1 Page Equals 3 FormsLQCN/A5196N/A1099-Q Payer Copy C and/or State/Copy1 Page Equals 3 FormsLRALRA50051405140B1099-R Federal Copy A1 Page Equals 2 FormsLRBLRB50051415141B1099-R Recipient Copy B1 Page Equals 2 FormsLRCLR2LRCLR250051425142B1099-R Recipient Copy C and/or State, City or Local or Copy 21 Page Equals 2 FormsLRD1LRD150051435143B1099-R Payer Copy D and/or State, City or Local1 Page Equals 2 Forms34"