b"PRE-PRINTED 1099 FORMSTXFXPX 1099DIV & 1099R PACKAGED SETSTFP 1099DIV PACKAGED LASER 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. 1545-0110PAYERS name, street address, city or town, state or province, country, ZIP 1aTotal ordinary dividendsOMB No. 1545-0110Form1096 Annual Summary and Transmittal of OMB No. 1545-0108 INKSDETACH BEFORE MAILINGINKSUSING HEATDETACH BEFORE MAILINGINKSUSING HEATDETACH BEFORE MAILING DETACH BEFORE MAILINGRESISTANTUSING HEATRESISTANTRESISTANTMANUFACTUREDMANUFACTURED ON OCR LASER BOND PAPER USING HEAT RESISTANT INKSor foreign postal code, and telephone no.or foreign postal code, and telephone no.or foreign postal code, and telephone no.(Rev. February 2021)$1b 2021 Distributions$1b 2021 Distributions$1b 2021 DistributionsDepartment of the TreasuryU.S. Information Returns 2021Dividends andDividends andDividends and Internal Revenue ServiceFILERS name$Form1099-DIV$Form1099-DIV$Form1099-DIV $2aTotal capital gain distr. $2bUnrecap. Sec. 1250 gainCopy AFor$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)2cSection 1202 gain2dCollectibles (28%) gainInternal RevenuePAYERS TINRECIPIENTS TIN 2cSection 1202 gain2dCollectibles (28%) gainFor RecipientPAYERS TINRECIPIENTS TIN 2cSection 1202 gain2dCollectibles (28%) gainFor PayerPAYERS TIN RECIPIENTS TIN and/or State $$Service Center$$$$ Copy 1 or Copy 2 BOND PAPERBOND PAPERBOND PAPER$2eSection 897 ordinary dividends $2fSection 897 capital gainFile with Form 1096. $2eSection 897 ordinary dividends $2fSection 897 capital gain$2eSection 897 ordinary dividends $2fSection 897 capital gainCity or town, state or province, country, and ZIP or foreign postal code For Ofcial Use OnlyRECIPIENTS name$3Nondividend distributions$4Federal income tax withheldand PaperworkRECIPIENT'S name, stret adres, city or town, state or province, country, and ZIP or foreign postal code $3Nondividend distributions$4Federal income tax withheldThis is important taxRECIPIENT'S name, stret adres, city or town, state or province, country, and ZIP or foreign postal code $3Nondividend distributions$4Federal income tax withheld For Privacy ActName of person to contact Telephone numberFor Privacy Actinformation and is5Section 199A dividends 6Investment expensesand PaperworkEmail address Fax numberbeing furnished to Street address (including apt. no.)$5Section 199A dividends $6Investment expensesReduction Act$5Section 199A dividends $6Investment expensesthe IRS. If you are$$Reduction ActON OCR LASERON OCR LASERON OCR LASER7Foreign 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. possession Notice, see the12 Social security number 3 Total number of forms 4 Federal income tax withheld5 Total amount reported with this Form 10962021 Generalpenalty or other2021 General$ $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 distributionssanction may be$9Cash liquidation distributions10 Noncash liquidation distributionsInstructions for Certain6W-2G 1097-BTC10981098-C1098-E1098-F1098-Q1098-T1099-A1099-B1099-C1099-CAP 1099-DIV1099-G1099-INT1099-K1099-LS imposed on you if Information this income is taxableInformation32 50 81 78 84 03 74 83 80 79 85 73 91 86 92 10 16and the IRSMANUFACTUREDMANUFACTURED$$Returns.$$determines that it has$$Returns. 11Exempt-interest dividends12bond interest dividends requirement 11Exempt-interest dividends12bond interest dividends not been reported.requirement 11Exempt-interest dividends12bond interest dividendsrequirement$$$$$$1099-LTC1099-MISC 1099-NEC 1099-OID1099- 1099-Q1099-QA 1099-R1099-S1099-SA 1099-SB 3921392254985498-ESA5498-QA 5498-SA Account number (see instructions)2nd TIN not. 13State 1415State tax withheld Account number (see instructions)13State 1415State tax withheld Account number (see instructions)2nd TIN not. 13State 1415State tax withheld 93 95 71 96 PATR31 1A 98 75 94 43 25 26 28 72 2A 2797$$$ $$$ Form1099-DIV41-0852411 www.irs.gov/Form1099DIV Department of the Treasury - Internal Revenue Service Form1099-DIV(keep for your records)www.irs.gov/Form1099DIV Department of the Treasury - Internal Revenue Service Form1099-DIVwww.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.or foreign postal code, and telephone no.or foreign postal code, and telephone no. Dividends andDividends andDividends andInstructions$1b 2021 Distributions$1b 2021 Distributions$1b 2021 DistributionsFuture developments. For the latest information about developmentsform must be the same as those you enter in the upper left area of related to Form 1096, such as legislation enacted after it was $Form1099-DIV$Form1099-DIV$Form1099-DIVpublished, go to www.irs.gov/Form1096. Forms 1097, 1098, 1099, 3921, 3922, 5498, or W-2G.Reminder. The only acceptable method of electronicallyWhen to le. File Form 1096 as follows.$2aTotal capital gain distr. $2bUnrecap. Sec. 1250 gainCopy AFor$2aTotal capital gain distr. $2bUnrecap. Sec. 1250 gainCopy B$2aTotal capital gain distr. $2bUnrecap. Sec. 1250 gainCopy C information returns listed on this form in box 6 with the IRS is throughFebruary 28, 2022.the FIRE System. See Pub. 1220. PAYERS TIN RECIPIENTS TIN 2cSection 1202 gain2dCollectibles (28%) gainInternal RevenuePAYERS TINRECIPIENTS TIN 2cSection 1202 gain2dCollectibles (28%) gainFor RecipientPAYERS TINRECIPIENTS TIN 2cSection 1202 gain2dCollectibles (28%) gainFor Payer Purpose of form. Use this form to transmit paper Forms 1097, 1098, $$Service Center$2eSection 897 ordinary dividends $2fSection 897 capital gain$2eSection 897 ordinary dividends $2fSection 897 capital gainand/or State1099, 3921, 3922, 5498, and W-2G to the IRS.Where To FileCopy 1 or Copy 2 Caution: 2eSection 897 ordinary dividends2fSection 897 capital gainFile with Form 1096. $$$$electronically but fail to do so, and you do not have an approved $$ RECIPIENTS name$3Nondividend distributions$4Federal income tax withheldand PaperworkRECIPIENT'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 Actwaiver, you may be subject to a penalty. The Taxpayer First Act offollowing. Use the following For Privacy Actinformation and is5Section 199A dividends 6Investment expensesand Paperwork2019, enacted July 1, 2019, authorized the Department of theIf your principal business, ofce being furnished toTreasury and the IRS to issue regulations that reduce the 250-return Street address (including apt. no.)$5Section 199A dividends $6Investment expensesReduction Act$5Section 199A dividends $6Investment expensesthe IRS. If you are$$Reduction Actrequirement for 2021 tax returns. If those regulations are issued andor agency, or legal residence inaddressNotice, see the7Foreign tax paid8Foreign country or U.S. possession return, a negligence7Foreign tax paid8Foreign country or U.S. possession Notice, see thean article at www.irs.gov/Form1099 explaining the change. Untilthe case of an individual, is located in7Foreign tax paid8Foreign country or U.S. possession 2021 Generalpenalty or other2021 Generalregulations are issued, however, the number remains at 250, aspart F in theAlabama, Arizona, Arkansas, Delaware,Internal Revenue Service City or town, state or province, country, and ZIP or foreign postal code $9Cash liquidation distributions10 Noncash liquidation distributions Instructions for Certain$9Cash liquidation distributions10 Noncash liquidation distributionssanction may be$9Cash liquidation distributions10 Noncash liquidation distributionsInstructions for Certain2021 General Instructions for Certain Information Returns. Florida, Georgia, Kentucky, Maine,Austin Submission Processing Center imposed on you if Information this income is taxableInformationof the number of returns. Massachusetts, Mississippi, NewP.O. Box 149213 and the IRSHampshire, New Jersey, New Mexico,Austin, TX 78714$$Returns.$$determines that it has$$Returns.Who must le.New York, North Carolina, Ohio, Texas, requirement 11Exempt-interest dividends12bond interest dividends requirement 11Exempt-interest dividends12bond interest dividends not been reported.requirement 11Exempt-interest dividends12bond interest dividends Vermont, Virginia$$$$$$ Account number (see instructions)2nd TIN not. 13State 1415State tax withheld Account number (see instructions)13State 1415State tax withheld Account number (see instructions)2nd TIN not. 13State 1415State tax withheld$$$ $$$For more information and the Privacy Act and Paperwork Reduction Act Notice,L1096 41-0852411 5100 Form1096(2021)Form1099-DIVLDA 41-0852411 5130 www.irs.gov/Form1099DIV Department of the Treasury - Internal Revenue Service Form1099-DIVLDB (keep for your records)5131 www.irs.gov/Form1099DIV Department of the Treasury - Internal Revenue Service Form1099-DIVLDC 5132 www.irs.gov/Form1099DIV Department of the Treasury - Internal Revenue Service see the 2021 General Instructions for Certain Information Returns.TFP 1099R PACKAGED LASER 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. 1545-0119 Distributions From1Gross 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 FromPAYERS name, street address, city or town, state or province,Distributions 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. (Rev. February 2021)country, ZIP or foreign postal code, and telephone no. Pensions, Annuities, Pensions, Annuities, Pensions, Annuities,Retirement orRetirement orRetirement orRetirement orU.S. Information Returns 2021$ 2aTaxable amount 2021 Prot-Sharing Plans,$ 2aTaxable amount 2021 Prot-Sharing Plans,$ 2aTaxable amount 2021 Prot-Sharing Plans,$ 2aTaxable amount 2021 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 2bnot determined 4 TotalPAYERS TINCopy ARECIPIENTS TIN 2bnot determined 4 TotalPAYERS TINCopyBRECIPIENTS TIN 2bTaxable amount4 TotalPAYERS TINCopy CRECIPIENTS TIN 2bTaxable amount4 TotalCopy D Taxable amountTaxable amount 3Capital gain (included indistribution For3Capital gain (included indistribution Report thisnot determined distribution For Recipient'snot determined distribution Street address (including room or suite number)Federal income tax Internal Revenuebox 2a) Federal income tax income on your3Capital gain (included inFederal income tax Records and/or 3Capital gain (included inFederal income tax For Payer box 2a) withheld Service Centerwithheld federal taxbox 2a) withheld State,City, box 2a) withheld a r d/orreturn. If thisor Locatl Tax State,nCity,lRECIPIENTS name $ 5Employee contributions/$ 6appreciation inFile with Form 1096. $ 5Employee contributions/$ 6appreciation inRECIPIENTS name, stre form shows$ 5Employee contributions/$ 6Net unrealizedRECIPIENTS name, stret adres orCopy2 $ 5Employee contributions/$ 6appreciation in Locat Telephone number For Ofcial Use OnlyDepoartmenTax Departmen City or town, state or province, country, and ZIP or foreign postal codeDesignated RothNet unrealized RECIPIENTS name, stret adres, city or town, state or province, country and ZIP or foreign postal code Designated RothNet unrealizedfederal incomeDesignated Rothappreciation in, city or town, state or province, country and ZIP or foreign postal code contributions orNet unrealized Name of person to contact Fax numbert adres, city or town, state or province, country and ZIP or foreign postal codecontributions oremployers securities For Privacy Actinsurance premiums employers securities tax withheld incontributions oremployers securities Designated Rothemployers securities For Privacy Act insurance premiums and Paperworkcontributions orbox 4, attachinsurance premiums insurance premiums and Paperwork Reduction ActEmail address Reduction Act $ IRA/ $ 8Other Notice, see the$ 7DistributionIRA/ $ 8Other this copy to$ 7DistributionIRA/ $ 8Other $ 7DistributionIRA/ $ 8Other 12 Social security number 3 Total number of forms 4 Federal income tax withheld5 Total amount reported with this Form 1096Street address (including apt. no.) 7DistributionSEP/2021 Generalcode(s) SIMPLE your return.code(s) SIMPLE This information iscode(s) SIMPLE 6 % Notice, see the $ $code(s) SIMPLE $ % Instructions for CertainSEP/ $ % This information isSEP/ $ % SEP/ $2021 General Instructions forCertain 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 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-BTCReturns. 78 84 03 74 83 80 79 85 73 91 86 92 10 1632 10988110Amount 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 distribution16State distribution 16State distribution 16State distributionwithin 5 years Roth contrib. within 5 years Roth contrib. within 5 years Roth contrib. within 5 years Roth contrib.$ $ $$ Account number (see instructions) 13Date of$ 17Local tax withheld 18Name of locality $ $ 19Local distribution 13Date of$ 17Local tax withheld 18Name of locality $ $ 19Local distribution 13Date of$ 17Local tax withheld 18Name of locality $ $ 19Local distribution 13Date of$ 17Local tax withheld 18Name of locality 1099-LTC1099-MISC 1099-NEC 1099-OID PATR1099-Q1099-QA 1099-R1099-S1099-SA 1099-SB 3921392254985498-ESA5498-QA 5498-SA Account number (see instructions) Account number (see instructions) Account number (see instructions) 93 $ 95 71 96 1099- 31 1A 98 75 94 43 25 26 28 72 2A 27payment$ $ payment$ $ payment$ $ payment$ $ 19Local distribution 97$ $ $ $ $ $ $ $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 DatePAYERS 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 Distributions From1Gross distribution OMB No. 1545-0119PAYERS name, street address, city or town, state or province,1Gross distribution OMB No. 1545-0119 SignatureDistributions FromPAYERS name, street address, city or town, state or province,Distributions FromDistributions From country, 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 2021 Prot-Sharing Plans,$ 2aTaxable amount 2021 Prot-Sharing Plans,$ 2aTaxable amount 2021 Prot-Sharing Plans,$ 2aTaxable amount 2021 Prot-Sharing Plans,form must be the same as those you enter in the upper left area of Future developments. For the latest information about developments IRAs, InsuranceIRAs, InsuranceIRAs, InsuranceIRAs, Insurance related to Form 1096, such as legislation enacted after it was Contracts, etc.$ Form 1099-R Contracts, etc. $ Form 1099-R Contracts, etc. $ Form 1099-R Contracts, etc. $ Form 1099-R published, go to www.irs.gov/Form1096. Forms 1097, 1098, 1099, 3921, 3922, 5498, or W-2G.Reminder. The only acceptable method of electronicallyWhen to le. File Form 1096 as follows.PAYERS TIN RECIPIENTS TIN 2bTaxable amount4 TotalPAYERS TINCopy ARECIPIENTS TIN 2bTaxable amount4 TotalPAYERS TINCopyBRECIPIENTS TIN 2bTaxable amount4 TotalPAYERS TINCopy CRECIPIENTS TIN 2bnot determined 4 Totalinformation returns listed on this form in box 6 with the IRS isthroughFebruary 28, 2022.not determined distribution not determined distribution Report thisnot determined distribution For Recipient'sTaxable amountdistribution Copy D the FIRE System. See Pub. 1220. For Payer 3Capital 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, return. If thisor Locatl State,anCity,lbox 2a) withheld Service Centerbox 2a) withheld federal taxbox 2a) withheld State,City, box 2a) withheld Caution:Tax r d/or Where To File1099, 3921, 3922, 5498, and W-2G to the IRS. Depoartmen$ $File with Form 1096. $ $ form shows$ $ Tax Departmen 2 $ $ LocatorCopy electronically but fail to do so, and you do not have an approved RECIPIENTS name 5Employee contributions/ 6Net unrealizedRECIPIENTS name, stret adres, city or town, state or province, country and ZIP or foreign postal code 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 RECIPIENTS name, stret adres, city or town, state or province, country and ZIP or foreign postal code 5Employee contributions/ 6appreciation in waiver, you may be subject to a penalty. The Taxpayer First Act offollowing.Designated Rothappreciation inFor Privacy ActDesignated RothNet unrealized federal incomeDesignated RothNet unrealized Designated RothNet unrealized2019, enacted July 1, 2019, authorized the Department of the Reduction Actcontributions orbox 4, attachcontributions orcontributions oremployers securities For Privacy Actor agency, or legal residence inaddresscontributions oremployers securities and Paperworkinsurance premiums employers securities tax withheld ininsurance premiums employers securities insurance premiums Treasury and the IRS to issue regulations that reduce the 250-returnIf your principal business, ofceUse the following and Paperwork insurance premiums this copy to$ $ $ $ requirement for 2021 tax returns. If those regulations are issued andthe case of an individual, is Reduction Act $ IRA/ $ 8Other Notice, see the$ 7DistributionIRA/ $ 8Other your return.7DistributionIRA/ 8Other 7DistributionIRA/ 8Other Notice, see thelocated inan article at www.irs.gov/Form1099 explaining the change. Until Street address (including apt. no.) 7DistributionSEP/2021 Generalcode(s) SEP/ code(s) SEP/ This information iscode(s) SIMPLE2021 GeneralAlabama, Arizona, Arkansas, Delaware,Internal Revenue Service code(s) SIMPLE % Instructions forSIMPLE % This information isSIMPLE $ % being furnished toSEP/ $ regulations are issued, however, the number remains at 250, aspart F in theFlorida, Georgia, Kentucky, Maine,Austin Submission Processing Center Instructions for Certain City or town, state or province, country, and ZIP or foreign postal code9aYour percentage of total$ Total employee contributions Certain9aYour percentage of total$ Total employee contributions being furnished to9aYour percentage of total 9bTotal employee contributions the IRS. 9aYour percentage of total 9b 2021 General Instructions for Certain Information Returns. Massachusetts, Mississippi, NewP.O. Box 149213 distribution %$ 9b Informationdistribution %$ 9b the IRS. distribution %$ distribution %$ % InformationHampshire, New Jersey, New Mexico,Austin, TX 78714Returns. Total employee contributions Returns.of the number of returns. New York, North Carolina, Ohio, Texas, 16State distribution 16State distribution 16State distribution Who must le.Vermont, Virginia10Amount 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.$ $ $$ $ $ $ $ $ $ $ $ $ $ $Account number (see instructions) 13Date of17Local tax withheld 18Name of localityAccount number (see instructions) 13Date of17Local tax withheld 18Name of localityAccount number (see instructions) 13Date of17Local tax withheld 18Name of localityAccount number (see instructions) 13Date of17Local tax withheld 18Name of locality 19Local distribution19Local distribution 19Local distribution 19Local distributionpayment$ $ payment$ $ payment$ $ payment$ $$ $ $ $ $ $ $ For more information and the Privacy Act and Paperwork Reduction Act Notice,L1096 41-0852411 5100 Form1096(2021)$Form 1099-R LRB Form 1099-R (keep for your records) Form 1099-R LRD1 see the 2021 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 ServiceTFP 77771 or 77772 required envelope3 Transmittal 1096 forms are included with each setTFP 1099-DIV PACKAGED LASER SET TFP 1099-R PACKAGED LASER SET PARTS PARTSFOR 50 EMPLOYEES FOR 50 EMPLOYEES61074-Part PRE-PACKAGED CONVENIENCE SET includes: 50 - 5130, 56444-Part PRE-PACKAGED CONVENIENCE SET includes: 50 - 5140,50- 5131, 100 - 5132, 3 - 5100 1096 50- 5141, 50 - 5142, 50 - 5143, 3 - 5100 1096FOR 25 EMPLOYEES 56466-Part PRE-PACKAGED CONVENIENCE SET includes: 50 - 5140,6107254-Part PRE-PACKAGED CONVENIENCE SET includes: 25 - 5130, 50- 5141, 100 - 5142, 100 - 5143, 3 - 5100 109625- 5131, 50 - 5132, 3 - 5100 1096 FOR 25 EMPLOYEES5644254-Part PRE-PACKAGED CONVENIENCE SET includes: 25 - 5140,25- 5141, 25 - 5142, 25 - 5143, 3 - 5100 10965646256-Part PRE-PACKAGED CONVENIENCE SET includes: 25 - 5140,25- 5141, 50 - 5142, 50 - 5143, 3 - 5100 109642"