b"1099 PRE-PRINTED FORMSTFP 1099-DIV & 1099-R Packaged SetsTFP 1099-DIV LASER PACKAGED SETTFP 5130 TFP 5131 TFP 5132 TFP 51009191 VOIDCORRECTED CORRECTED (if checked) VOIDCORRECTED Do Not Staple 6969PAYERS name, street address, city or town, state or province, country, ZIP 1aTotal ordinary dividendsOMB No. 1545-0110PAYERS name, street address, city or town, state or province, country, ZIP 1aTotal ordinary dividendsOMB No. 1545-0110Dividends andPAYERS name, street address, city or town, state or province, country, ZIP$1aTotal ordinary dividendsOMB No. 1545-0110Dividends andForm1096 Annual Summary and Transmittal of OMB No. 1545-0108or foreign postal code, and telephone no.$1b Form1099-DIVDividends andor foreign postal code, and telephone no. INKS $1b Form1099-DIV Distributions DETACH BEFORE MAILING or foreign postal code, and telephone no. USING HEATINKS 1b Form1099-DIVDistributions DETACH BEFORE MAILINGUSING HEATINKS Department of the TreasuryU.S. Information Returns 2022DETACH BEFORE MAILING DETACH BEFORE MAILINGRESISTANTUSING HEATRESISTANTRESISTANTMANUFACTUREDMANUFACTURED ON OCR LASER BOND PAPER USING HEAT RESISTANT INKS(Rev. January 2022) Distributions(Rev. January 2022) (Rev. January 2022) Internal Revenue ServiceFor calendar year For calendar year For calendar year FILERS name$20 $20 $20$ $2aTotal capital gain distr. $2bUnrecap. Sec. 1250 gainCopy A $2aTotal capital gain distr. $2bUnrecap. Sec. 1250 gainCopy B$2aTotal capital gain distr. $2bUnrecap. Sec. 1250 gainCopy C Street address (including room or suite number)Copy APAYERS TIN RECIPIENTS TIN 2cSection 1202 gain2dCollectibles (28%) gainInternal Revenue ForPAYERS TINRECIPIENTS TIN 2cSection 1202 gain2dCollectibles (28%) gainFor RecipientPAYERS TINRECIPIENTS TIN 2cSection 1202 gain2dCollectibles (28%) gainFor Payer$$Service Center$$$$and/or State Copy 1 or Copy 2 BOND PAPERBOND PAPERBOND PAPER$2eSection 897 ordinary dividends $2fSection 897 capital gainFile with Form 1096. $2eSection 897 ordinary dividends $2fSection 897 capital gain$2eSection 897 ordinary dividends $2fSection 897 capital gainCity or town, state or province, country, and ZIP or foreign postal code For Ofcial Use OnlyRECIPIENTS name3Nondividend distributions 4Federal income tax withheldRECIPIENT'S name, stret adres, city or town, state or province, country, and ZIP or foreign postal code3Nondividend distributions 4Federal income tax withheldThis is important taxRECIPIENT'S name, stret adres, city or town, state or province, country, and ZIP or foreign postal code $3Nondividend distributions$4Federal income tax withheld For Privacy ActName of person to contact Telephone number$$For Privacy Act$$information and isand PaperworkEmail address Fax number5Section 199A dividends 6Investment expensesand Paperwork5Section 199A dividends 6Investment expensesbeing furnished to5Section 199A dividends 6Investment expensesReduction Act Street address (including apt. no.)$$Reduction Act$$the IRS. If you are$$Notice, see the12 Social security number 3 Total number of forms 4 Federal income tax withheld5 Total amount reported with this Form 1096 ON OCR LASERON OCR LASERON OCR LASERNotice, see the 7Foreign tax paid8Foreign country or U.S. possession Notice, see the7Foreign tax paid8Foreign country or U.S. possession return, a negligence7Foreign tax paid8Foreign country or U.S. possessioncurrent General$ $current Generalpenalty or other City or town, state or province, country, and ZIP or foreign postal code $9Cash liquidation distributions10 Noncash liquidation distributions Instructions for Certain$9Cash liquidation distributions10 Noncash liquidation distributionsimposed on you if$9Cash liquidation distributions10 Noncash liquidation distributionsInstructions for6W-2G 1097-BTC10981098-C1098-E1098-F1098-Q1098-T1099-A1099-B1099-C1099-CAP 1099-DIV1099-G1099-INT1099-K1099-LS sanction may be Information this income is taxableCertain32 50 81 78 84 03 74 83 80 79 85 73 91 86 92 10 16determines that it has$$Information and the IRSMANUFACTUREDMANUFACTURED$$Returns.$$not been reported.12Exempt-interest dividends13bond interest dividends Returns. 11requirement 12Exempt-interest dividends13bond interest dividends 11requirement 12Exempt-interest dividends13bond interest dividends 11requirement$$$$$$1099-LTC1099-MISC 1099-NEC 1099-OID1099-PATR1099-Q1099-QA 1099-R1099-S1099-SA 1099-SB 3921392254985498-ESA5498-QA 5498-SA Account number (see instructions)2nd TIN not.14State 1516State tax withheld Account number (see instructions)14State 1516State tax withheld Account number (see instructions)2nd TIN not.14State 1516State tax withheld 93 95 71 96 97 31 1A 98 75 94 43 25 26 28 72 2A 27$$$ $ $$$ $ Form1099-DIV(Rev. 1-2022) 41-0852411 www.irs.gov/Form1099DIV Department of the Treasury - Internal Revenue Service Form1099-DIV(Rev. 1-2022) (keep for your records)www.irs.gov/Form1099DIV Department of the Treasury - Internal Revenue Service Form1099-DIV(Rev. 1-2022) www.irs.gov/Form1099DIV Department of the Treasury - Internal Revenue Service Return this entire page to the Internal Revenue Service. Photocopies are not acceptable. DoNotCutorSeparateFormsonThisPage DoNotCutorSeparateFormsonThisPage Send this form, with the copies of the form checked in box 6, to the IRS in a at mailer (not folded).Under penalties of perjury, I declare that I have examined this return and accompanying documents and, to the best of my knowledge and belief, they are true, correct, and complete.9191 VOIDCORRECTED CORRECTED (if checked) VOIDCORRECTEDTitle DatePAYERS name, street address, city or town, state or province, country, ZIP 1aTotal ordinary dividendsOMB No. 1545-0110PAYERS name, street address, city or town, state or province, country, ZIP 1aTotal ordinary dividendsOMB No. 1545-0110PAYERS name, street address, city or town, state or province, country, ZIP 1aTotal ordinary dividendsOMB No. 1545-0110Signatureor foreign postal code, and telephone no.$Form1099-DIVDividends andor foreign postal code, and telephone no.$Form1099-DIV Dividends andor foreign postal code, and telephone no.$Form1099-DIVDividends andInstructions1b (Rev. January 2022) Distributions1b (Rev. January 2022) Distributions1b (Rev. January 2022) DistributionsFuture developments. For the latest information about developmentsform must be the same as those you enter in the upper left area of For calendar year For calendar year For calendar year related to Form 1096, such as legislation enacted after it wasForms 1097, 1098, 1099, 3921, 3922, 5498, or W-2G.published, go to www.irs.gov/Form1096.$2aTotal capital gain distr. $20 $2aTotal capital gain distr. $20 Copy B$2aTotal capital gain distr. $20 Copy C Reminder. The only acceptable method of electronicallyWhen to le. File Form 1096 as follows.information returns listed on this form in box 6 with the IRS is through $2bUnrecap. Sec. 1250 gainCopy AForPAYERS TINRECIPIENTS TIN $2cSection 1202 gain2bUnrecap. Sec. 1250 gainFor RecipientPAYERS TINRECIPIENTS TIN $2cSection 1202 gain2bUnrecap. Sec. 1250 gainFor Payer the FIRE System. See Pub. 1220.February 28, 2023.PAYERS TIN RECIPIENTS TIN 2cSection 1202 gain2dCollectibles (28%) gainInternal Revenue2dCollectibles (28%) gain2dCollectibles (28%) gainand/or StatePurpose of form. Use this form to transmit paper Forms 1097, 1098, $$Service Center$$$$ Copy 1 or Copy 2 1099, 3921, 3922, 5498, and W-2G to the IRS. 2eSection 897 ordinary dividends2fSection 897 capital gainFile with Form 1096. $2eSection 897 ordinary dividends $2fSection 897 capital gain$2eSection 897 ordinary dividends $2fSection 897 capital gainCaution: electronically but fail to do so, and you do notWhere To File$$have an approved waiver, you may be subject to a penalty. Thefollowing.RECIPIENTS name3Nondividend distributions 4Federal income tax withheldRECIPIENT'S name, stret adres, city or town, state or province, country, and ZIP or foreign postal code $3Nondividend distributions 4Federal income tax withheldThis is important taxRECIPIENT'S name, stret adres, city or town, state or province, country, and ZIP or foreign postal code $3Nondividend distributions$4Federal income tax withheld For Privacy ActDepartment of the Treasury and the IRS to issue regulations thatIf your principal business, ofceUse the following Taxpayer First Act of 2019, enacted July 1, 2019, authorized the $$For Privacy Act$information and isand Paperworkreduce the 250-return requirement for 2021 tax returns. If thoseor agency, or legal residence inaddress5Section 199A dividends 6Investment expensesand Paperwork$5Section 199A dividends $6Investment expensesbeing furnished to$5Section 199A dividends $6Investment expensesReduction Actregulations are issued and effective for 2022 tax returns required to be www.irs.gov/Form1099the case of an individual, is Street address (including apt. no.)$$Reduction Actthe IRS. If you areNotice, see theexplaining the change. Until regulations are issued, however, thelocated in7Foreign tax paid8Foreign country or U.S. possession Notice, see the7Foreign tax paid8Foreign country or U.S. possession return, a negligence7Foreign tax paid8Foreign country or U.S. possessioncurrent General current Generalpenalty or other City or town, state or province, country, and ZIP or foreign postal code $9Cash liquidation distributions10 Noncash liquidation distributions Instructions for Certain$9Cash liquidation distributions10 Noncash liquidation distributionsimposed on you if$9Cash liquidation distributions10 Noncash liquidation distributionsInstructions for CertainInformation Returns. part F in the 2022 General Instructions for CertainAlabama, Arizona, Arkansas, Delaware,Internal Revenue Servicesanction may beinformation, see Florida, Georgia, Kentucky, Maine, Information this income is taxableInformationMassachusetts, Mississippi, NewP.O. Box 149213 and the IRSHampshire, New Jersey, New Mexico, $$Returns.$$determines that it has$$Returns.of the number of returns. New York, North Carolina, Ohio, Texas,Austin, TX 78714-921311requirement 12Exempt-interest dividends13bond interest dividends 11requirement 12Exempt-interest dividends13bond interest dividends not been reported.11requirement 12Exempt-interest dividends13bond interest dividends Who must le.Vermont, Virginia$$$$$$Caution: Your name and TIN must match the name and TIN used on your 94X series tax return(s) or you may be subject to information Account number (see instructions)2nd TIN not.14State 1516State tax withheld Account number (see instructions)14State 1516State tax withheld Account number (see instructions)2nd TIN not.14State 1516State tax withheld return penalties. Do not use the name and/or TIN of your paying agent $$$or service bureau.$$$For more information and the Privacy Act and Paperwork Reduction Act Notice,L1096 41-0852411 5100 Form1096(2022)Form1099-DIV(Rev. 1-2022) LDA 41-0852411 5130 www.irs.gov/Form1099DIV Department of the Treasury - Internal Revenue Service Form1099-DIV(Rev. 1-2022)LDB (keep for your records)5131 www.irs.gov/Form1099DIV Department of the Treasury - Internal Revenue Service Form1099-DIV(Rev. 1-2022) LDC 5132 www.irs.gov/Form1099DIV Department of the Treasury - Internal Revenue Service see the 2022 General Instructions for Certain Information Returns.TFP 1099-R LASER PACKAGED SETTFP 5140 TFP 5141 TFP 5142 TFP 5143 TFP 51009898 VOID CORRECTED CORRECTED (if checked) CORRECTED (if checked) VOID CORRECTED Do Not Staple 6969PAYERS name, street address, city or town, state or province,1Gross distribution OMB No. 1545-0119PAYERS name, street address, city or town, state or province,1Gross distribution OMB No. 1545-0119PAYERS name, street address, city or town, state or province,1Gross distribution OMB No. 1545-0119PAYERS name, street address, city or town, state or province,1Gross distribution OMB No. 1545-0119 Form1096 Annual Summary and Transmittal of OMB No. 1545-0108 DETACH BEFORE MAILINGDETACH BEFORE MAILINGDETACH BEFORE MAILINGDETACH BEFORE MAILINGDETACH BEFORE MAILINGDistributions FromDistributions FromDistributions FromDistributions FromMANUFACTURED ON OCR LASER BOND PAPER USING HEAT RESISTANT INKSMANUFACTURED ON OCR LASER BOND PAPER USING HEAT RESISTANT INKSMANUFACTURED ON OCR LASER BOND PAPER USING HEAT RESISTANT INKSMANUFACTURED ON OCR LASER BOND PAPER USING HEAT RESISTANT INKSMANUFACTURED ON OCR LASER BOND PAPER USING HEAT RESISTANT INKScountry, ZIP or foreign postal code, and telephone no. Pensions, Annuities, country, ZIP or foreign postal code, and telephone no. country, ZIP or foreign postal code, and telephone no. Pensions, Annuities,country, ZIP or foreign postal code, and telephone no. Pensions, Annuities, Pensions, Annuities,Retirement orRetirement orRetirement orRetirement orU.S. Information Returns 2022$ 2aTaxable amount 2022 Prot-Sharing Plans,$ 2aTaxable amount 2022 Prot-Sharing Plans,$ 2aTaxable amount 2022 Prot-Sharing Plans,$ 2aTaxable amount 2022 Department of the Treasury Prot-Sharing Plans, Internal Revenue ServiceIRAs, InsuranceIRAs, InsuranceIRAs, InsuranceFILERS nameIRAs, Insurance $ Form 1099-R Contracts, etc. $ Form 1099-R Contracts, etc. $ Form 1099-R Contracts, etc. $ Form 1099-R Contracts, etc.PAYERS TIN RECIPIENTS TIN 2bTaxable amount4 TotalPAYERS TINCopy ARECIPIENTS TIN 2bnot determined 4 TotalPAYERS TINCopyBRECIPIENTS TIN 2bnot determined 4 TotalPAYERS TINCopy CRECIPIENTS TIN 2bnot determined 4 TotalCopy D Taxable amountTaxable amountTaxable amount not determined distribution For3Capital gain (included indistribution Report this3Capital gain (included indistribution For Recipient's3Capital gain (included indistribution Street address (including room or suite number)3Capital gain (included inFederal income tax Internal Revenuebox 2a) Federal income tax income on yourbox 2a) Federal income tax Records and/or box 2a) Federal income tax For Payer box 2a) withheld Service Centerwithheld federal taxwithheld State,City, withheld a r d/orreturn. If thisor Locatl Tax State,nCity,lDepoartmenRECIPIENTS name $ 5Employee contributions/$ 6Net unrealizedFile with Form 1096. $ 5Employee contributions/$ 6appreciation in RECIPIENTS name, stre form shows$ 5Employee contributions/$ 6appreciation in RECIPIENTS name, stret adres orCopy2 $ 5Employee contributions/$ 6appreciation in Locat Telephone number For Ofcial Use OnlyTax Departmen City or town, state or province, country, and ZIP or foreign postal codeDesignated Rothappreciation in For Privacy ActDesignated RothNet unrealized federal incomeDesignated RothNet unrealized , city or town, state or province, country and ZIP or foreign postal code Designated RothNet unrealized Name of person to contactRECIPIENTS name, stret adres, city or town, state or province, country and ZIP or foreign postal code t adres, city or town, state or province, country and ZIP or foreign postal codecontributions oremployers securities and Paperworkcontributions oremployers securities tax withheld incontributions oremployers securities contributions oremployers securities For Privacy ActFax numberand Paperwork insurance premiums Reduction Actinsurance premiums box 4, attachinsurance premiums $ insurance premiums Email address Reduction Act2 Social security number 3 Total number of forms 4 Federal income tax withheld5 Total amount reported with this Form 1096$ code(s) IRA/ $ 8Other Notice, see the$ 7DistributionSEP/ $ 8Other this copy to$ 7DistributionSEP/ $ 8Other This information is7DistributionSEP/ $ 8Other 1Notice, see the$ $Street address (including apt. no.) 7DistributionSEP/2022 Generalcode(s) IRA/ your return.code(s) IRA/ code(s) IRA/2022 General SIMPLE $ % Instructions for CertainSIMPLE $ % This information isSIMPLE $ % SIMPLE $ 6 % Instructions forCertainCity or town, state or province, country, and ZIP or foreign postal code9aYour percentage of total 9bTotal employee contributions Information9aYour percentage of total 9bTotal employee contributions being furnished to the IRS. 9aYour percentage of total 9bTotal employee contributions being furnished to the IRS. 9aYour percentage of total 9bTotal employee contributions 50 Information1098-C1098-E1098-F 1098-Q1098-T1099-A1099-B1099-C1099-CAP 1099-DIV1099-G1099-INT1099-K1099-LS distribution %$ Returns. distribution %$ distribution %$ distribution %$ W-2G 1097-BTC1098 78 84 03 74 83 80 79 85 73 91 86 92 10 1632 Returns.8116State distribution 16State distribution 16State distribution10Amount allocable to IRR111st year of desig. 12 requirement$ 14State tax withheld 15State/Payers state no.10Amount allocable to IRR111st year of desig. 12 requirement$ 14State tax withheld 15State/Payers state no.10Amount allocable to IRR111st year of desig. 12 requirement$ 14State tax withheld 15State/Payers state no.10Amount allocable to IRR111st year of desig. 12 requirement$ 14State tax withheld 15State/Payers state no. $ 16State distributionwithin 5 years Roth contrib. within 5 years Roth contrib. within 5 years Roth contrib. within 5 years Roth contrib.$ $ $$ $ $ $ $ $ $ $ $ $ $ 1099-LTC1099-MISC 1099-NEC 1099-OID1099-PATR1099-Q1099-QA 1099-R1099-S1099-SA 1099-SB 3921392254985498-ESA5498-QA 5498-SA 93 $ 19Local distribution 96 97 31 1A 98 75 94 43 25 26 28 72 2A 27Account number (see instructions) 13Date of17Local tax withheld 18Name of localityAccount number (see instructions) 13Date of17Local tax withheld 18Name of localityAccount number (see instructions) 13Date of17Local tax withheld 18Name of localityAccount number (see instructions) 13Date of17Local tax withheld 18Name of locality 95 7119Local distribution 19Local distribution 19Local distributionpayment$ $ payment$ $ payment$ $ payment$ $$ $ $ $ $ $ $ $Form 1099-R Form 1099-R (keep for your records) Form 1099-R Return this entire page to the Internal Revenue Service. Photocopies are not acceptable. Form 1099-R 41-0852411 www.irs.gov/Form1099R Department of the Treasury - Internal Revenue Service www.irs.gov/Form1099R Department of the Treasury - Internal Revenue Service www.irs.gov/Form1099R Department of the Treasury - Internal Revenue Service www.irs.gov/Form1099R Department of the Treasury - Internal Revenue ServiceDoNotCutorSeparateFormsonThisPage DoNotCutorSeparateFormsonThisPage Send this form, with the copies of the form checked in box 6, to the IRS in a at mailer (not folded).Under penalties of perjury, I declare that I have examined this return and accompanying documents and, to the best of my knowledge and belief, they are true, correct, and complete.9898 VOID CORRECTED CORRECTED (if checked) CORRECTED (if checked) VOID CORRECTEDTitle DateDistributions FromDistributions FromDistributions FromDistributions From PAYERS name, street address, city or town, state or province,1Gross distribution OMB No. 1545-0119PAYERS name, street address, city or town, state or province,1Gross distribution OMB No. 1545-0119PAYERS name, street address, city or town, state or province,1Gross distribution OMB No. 1545-0119PAYERS name, street address, city or town, state or province,1Gross distribution OMB No. 1545-0119 Signaturecountry, ZIP or foreign postal code, and telephone no. Pensions, Annuities, Pensions, Annuities, Pensions, Annuities, Pensions, Annuities,country, ZIP or foreign postal code, and telephone no. country, ZIP or foreign postal code, and telephone no. country, ZIP or foreign postal code, and telephone no.Retirement orRetirement orRetirement orInstructionsRetirement or $ 2aTaxable amount 2022 Prot-Sharing Plans,$ 2aTaxable amount 2022 Prot-Sharing Plans,$ 2aTaxable amount 2022 Prot-Sharing Plans,$ 2aTaxable amount 2022 Future developments. For the latest information about developmentsform must be the same as those you enter in the upper left area of Prot-Sharing Plans, IRAs, Insurance IRAs, InsuranceIRAs, InsuranceIRAs, Insurancerelated to Form 1096, such as legislation enacted after it was Contracts, etc.Contracts, etc. published, go to www.irs.gov/Form1096.$ Form 1099-R Contracts, etc. $ Form 1099-R Contracts, etc. $ Form 1099-R $ Form 1099-R Reminder. The only acceptable method of electronically throughForms 1097, 1098, 1099, 3921, 3922, 5498, or W-2G.When to le. File Form 1096 as follows.2bTaxable amountTotalCopy A2bTaxable amountTotalCopyB2bTaxable amountTotalCopy C2bTaxable amountTotalinformation returns listed on this form in box 6 with the IRS isPAYERS TIN RECIPIENTS TIN not determined 4 distribution PAYERS TINRECIPIENTS TIN not determined 4 distribution PAYERS TINReport thisRECIPIENTS TIN not determined 4 distribution For Recipient'sRECIPIENTS TIN not determined 4 distribution Copy DFebruary 28, 2023.the FIRE System. See Pub. 1220. File with Form 1096. PAYERS TIN State,City, box 2a) withheld Caution:For Payerr Where To File3Capital gain (included inFederal income tax Internal Revenue For3Capital gain (included inFederal income tax income on your3Capital gain (included inFederal income tax Records and/or 3Capital gain (included inFederal income tax Purpose of form. Use this form to transmit paper Forms 1097, 1098, box 2a) withheld Service Centerbox 2a) withheld federal taxbox 2a) withheld and/or1099, 3921, 3922, 5498, and W-2G to the IRS. State,return. If thisor Locatl Tax City,l$ $ $ $ form shows$ $ Tax Departmen 2 $ $ LocatorCopy Depoartmen electronically but fail to do so, and you do not RECIPIENTS name, stret adres, city or town, state or province, country and ZIP or foreign postal code have an approved waiver, you may be subject to a penalty. The RECIPIENTS name 5Employee contributions/ 6appreciation in RECIPIENTS name, stret adres, city or town, state or province, country and ZIP or foreign postal code 5Employee contributions/ 6appreciation in federal income5Employee contributions/ 6appreciation in RECIPIENTS name, stret adres, city or town, state or province, country and ZIP or foreign postal code 5Employee contributions/ 6appreciation in Taxpayer First Act of 2019, enacted July 1, 2019, authorized thefollowing.Designated RothNet unrealized For Privacy Actcontributions orNet unrealized tax withheld inDesignated RothNet unrealized Designated RothNet unrealized For Privacy ActIf your principal business, ofceUse the following contributions orDesignated Rothcontributions orcontributions orDepartment of the Treasury and the IRS to issue regulations that insurance premiums employers securities and Paperworkinsurance premiums employers securities box 4, attachinsurance premiums employers securities insurance premiums employers securities and Paperworkor agency, or legal residence inaddressReduction Actthis copy to$ $ $ $ reduce the 250-return requirement for 2021 tax returns. If thosethe case of an individual, is $ IRA/ $ 8Other Notice, see the$ 7DistributionIRA/ $ 8Other your return.7DistributionIRA/ 8Other 7DistributionIRA/ 8Other Reduction Actlocated inregulations are issued and effective for 2022 tax returns required to be www.irs.gov/Form1099 Notice, see the Street address (including apt. no.) 7DistributionSEP/ $ %2022 Generalcode(s) SEP/ $ % This information iscode(s) SIMPLE $ % This information iscode(s) SIMPLE $ %2022 General Alabama, Arizona, Arkansas, Delaware,Internal Revenue ServiceSEP/ SEP/ explaining the change. Until regulations are issued, however, the Instructions forcode(s) SIMPLE Instructions for CertainSIMPLE Information Returns. part F in the 2022 General Instructions for CertainFlorida, Georgia, Kentucky, Maine, information, see Certain City or town, state or province, country, and ZIP or foreign postal code9aYour percentage of total 9bTotal employee contributions Information9aYour percentage of total 9bTotal employee contributions being furnished to the IRS. 9aYour percentage of total 9bTotal employee contributions being furnished to the IRS. 9aYour percentage of total 9bTotal employee contributions InformationMassachusetts, Mississippi, NewP.O. Box 149213 distribution %$ Returns. distribution %$ distribution %$ distribution %$ Returns. New York, North Carolina, Ohio, Texas,Austin, TX 78714-9213of the number of returns. Hampshire, New Jersey, New Mexico, 10Amount allocable to IRR111st year of desig. 12 requirement$ 14State tax withheld 15State/Payers state no.10Amount allocable to IRR111st year of desig. 12 requirement$ 14State tax withheld 15State/Payers state no.10Amount allocable to IRR111st year of desig. 12 requirement$ 14State tax withheld 15State/Payers state no.10Amount allocable to IRR111st year of desig. 12 requirement$ 14State tax withheld 15State/Payers state no. $ 16State distribution Vermont, Virginia16State distribution 16State distribution 16State distribution Who must le. within 5 years Roth contrib. within 5 years Roth contrib. within 5 years Roth contrib. within 5 years Roth contrib.$ $ $ Caution: Your name and TIN must match the name and TIN used on $ $ $ $ $ $ $ $ $ $ $ $Account number (see instructions) 13Date of17Local tax withheld 18Name of localityAccount number (see instructions) 13Date of17Local tax withheld 18Name of localityAccount number (see instructions) 13Date of17Local tax withheld 18Name of localityAccount number (see instructions) 13Date of17Local tax withheld 18Name of locality your 94X series tax return(s) or you may be subject to information 19Local distribution 19Local distribution 19Local distribution 19Local distributionreturn penalties. Do not use the name and/or TIN of your paying agent payment$ $ payment$ $ payment$ $ payment$ or service bureau.$$ $ $ $ $ $ $ For more information and the Privacy Act and Paperwork Reduction Act Notice,L1096 41-0852411 5100 Form1096(2022)$Form 1099-R LRB Form 1099-R (keep for your records) Form 1099-R LRD1 see the 2022 General Instructions for Certain Information Returns.Form 1099-R LRA 41-0852411 5140 www.irs.gov/Form1099R Department of the Treasury - Internal Revenue Service 5141 www.irs.gov/Form1099R Department of the Treasury - Internal Revenue Service LRC/LR2 www.irs.gov/Form1099R 5142 Department of the Treasury - Internal Revenue Service 5143 www.irs.gov/Form1099R Department of the Treasury - Internal Revenue ServiceRequired Envelope:(3) 1096 Transmittal forms are included with each set TFP: 77771 or 77772TFP 1099-DIV LASER PACKAGED SET* TFP 1099-R LASER PACKAGED SET FOR 50 EMPLOYEES FOR 50 EMPLOYEES61074-Part PRE-PACKAGED CONVENIENCE SET includes: 56444-Part PRE-PACKAGED CONVENIENCE SET includes:5130 (50), 5131 (50), 5132 (100), 5100 - 1096 (3) 5140 (50), 5141 (50), 5142 (50), 5143 (50),5100 - 1096 (3)FOR 25 EMPLOYEES 56466-Part PRE-PACKAGED CONVENIENCE SET includes:6107254-Part PRE-PACKAGED CONVENIENCE SET includes: 5140 (50), 5141 (50), 5142 (100), 5143 (100), 5100 - 1096 (3)5130 (25), 5131 (25), 5132 (50), 5100 - 1096 (3) FOR 25 EMPLOYEES5644254-Part PRE-PACKAGED CONVENIENCE SET includes:5140 (25), 5141 (25), 5142 (25), 5143 (25), 5100 - 1096 (3)5646256-Part PRE-PACKAGED CONVENIENCE SET includes:5140 (25), 5141 (25), 5142 (50), 5143 (50), 5100 - 1096 (3)41"