b"PRE-PRINTED 1099 FORMSAXPXEXX 1099DIV & 1099R PACKAGED SETSAPEX 1099DIV PACKAGED LASER SETAPEX LDA APEX LDB APEX LDC APEX L10969191 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 HEATRESISTANTRESISTANTMANUFACTURED 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$1b 2021 Department of the Treasury2021Dividends andDividends andDividends andU.S. Information ReturnsDistributions Internal Revenue ServiceFILERS name$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 CFor RecipientRECIPIENTS TIN 2cSection 1202 gain2dCollectibles (28%) gainStreet address (including room or suite number)PAYERS TINFor PayerPAYERS TIN RECIPIENTS TIN 2cSection 1202 gain2dCollectibles (28%) gainInternal RevenueRECIPIENTS TIN 2cSection 1202 gain2dCollectibles (28%) gainPAYERS TINand/or State $$Service Center$$$$ Copy 1 or Copy 2 BOND PAPERBOND PAPERBOND PAPER$2eSection 897 ordinary dividends $2fSection 897 capital gainFile with Form 1096. $2eSection 897 ordinary dividends $2fSection 897 capital gain$2eSection 897 ordinary dividends $2fSection 897 capital gainCity or town, state or province, country, and ZIP or foreign postal code For Ofcial Use OnlyRECIPIENTS name3Nondividend distributions 4Federal income tax withheld RECIPIENT'S name, stret adres, city or town, state or province, country, and ZIP or foreign postal code3Nondividend distributions 4Federal income tax withheld RECIPIENT'S name, stret adres, city or town, state or province, country, and ZIP or foreign postal code3Nondividend distributions 4Federal income tax withheldName of person to contact Telephone number$$For Privacy Act$$This is important tax$$For Privacy Act and Paperwork5Section 199A dividends 6Investment expensesinformation and is5Section 199A dividends 6Investment expensesand PaperworkFax numberbeing furnished toEmail address5Section 199A dividends 6Investment expensesReduction Act$$the IRS. If you are$$Reduction ActON OCR LASERON OCR LASERON OCR LASERStreet address (including apt. no.)$7Foreign tax paid$8Foreign country or U.S. possession Notice, see the7Foreign tax paid8Foreign country or U.S. possession return, a negligence7Foreign tax paid8Foreign country or U.S. possession1Notice, see the2 Social security number 3 Total number of forms 4 Federal income tax withheld5 Total amount reported with this Form 10962021 Generalpenalty or other2021 General$ $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 distributionsimposed on you if$9Cash liquidation distributions10 Noncash liquidation distributionsInstructions for Certain10981098-C1098-E1098-F 1098-Q1098-T1099-A1099-B1099-C1099-CAP 1099-DIV1099-G1099-INT1099-K1099-LS sanction may bethis income is taxable6W-2G 1097-BTC 81 78 84 03 74 83 80 79 85 73 91 86 92 10 16Informationand the IRS32 Information 50 MANUFACTUREDMANUFACTUREDMANUFACTURED$$Returns.$$determines that it has$$Returns. requirement 11Exempt-interest dividends12bond interest dividends requirement 11Exempt-interest dividends12bond interest dividends not been reported.requirement 11Exempt-interest dividends12bond interest dividends$$$$$$1099-LTC1099-MISC 1099-NEC 1099-OID1099- 1099-Q1099-QA 1099-R1099-S1099-SA 1099-SB 3921392254985498-ESA5498-QA 5498-SA Account number (see instructions)2nd TIN not. 13State 1415State tax withheld Account number (see instructions)13State 1415State tax withheld Account number (see instructions)2nd TIN not. 13State 1415State tax withheld 93 95 71 96 PATR31 1A 98 75 94 43 25 26 28 72 2A 2797$$$ $$$ Form1099-DIV41-0852411 www.irs.gov/Form1099DIV Department of the Treasury - Internal Revenue ServiceForm1099-DIV(keep for your records)www.irs.gov/Form1099DIV Department of the Treasury - Internal Revenue ServiceForm1099-DIVwww.irs.gov/Form1099DIV Department of the Treasury - Internal Revenue ServiceDoNotCutorSeparateFormsonThisPage DoNotCutorSeparateFormsonThisPage Return this entire page to the Internal Revenue Service. Photocopies are not acceptable. 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) VOIDCORRECTED Title 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. InstructionsDividends andDividends andDividends and $1b 2021 Distributions$1b 2021 Distributions$1b 2021 Future developments. For the latest information about developmentsform must be the same as those you enter in the upper left area of Distributions 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 electronically When to le. File Form 1096 as follows.$2aTotal capital gain distr. $2bUnrecap. Sec. 1250 gainPAYERS TINCopy AForRECIPIENTS TIN $2aTotal capital gain distr. $2bUnrecap. Sec. 1250 gainPAYERS TINCopy BRECIPIENTS TIN $2aTotal capital gain distr. $2bUnrecap. Sec. 1250 gainCopy C February 28, 2022.information returns listed on this form in box 6 with the IRS is through PAYERS TIN RECIPIENTS TIN 2cSection 1202 gain2dCollectibles (28%) gainInternal Revenue2cSection 1202 gain2dCollectibles (28%) gainFor Recipient2cSection 1202 gain2dCollectibles (28%) gainthe FIRE System. See Pub. 1220. For PayerPurpose of form. Use this form to transmit paper Forms 1097, 1098, $$Service Center$$$$and/or State 1099, 3921, 3922, 5498, and W-2G to the IRS. Copy 1 or Copy 2Caution: $2eSection 897 ordinary dividends $2fSection 897 capital gainFile with Form 1096. $2eSection 897 ordinary dividends $2fSection 897 capital gain$2eSection 897 ordinary dividends $2fSection 897 capital gainelectronically but fail to do so, and you do not have an approvedWhere To FileRECIPIENTS name$3Nondividend distributions$4Federal income tax withheld RECIPIENT'S name, stret adres, city or town, state or province, country, and ZIP or foreign postal code $3Nondividend distributions$4Federal income tax withheld RECIPIENT'S name, stret adres, city or town, state or province, country, and ZIP or foreign postal code $3Nondividend distributions$4Federal income tax withheld waiver, you may be subject to a penalty. The Taxpayer First Act offollowing. Use the followingAPEX DWMR or For Privacy ActThis is important tax2019, enacted July 1, 2019, authorized the Department of the and Paperwork5Section 199A dividends 6Investment expensesinformation and is5Section 199A dividends 6Investment expensesFor Privacy ActIf your principal business, ofce being furnished toTreasury and the IRS to issue regulations that reduce the 250-return and Paperwork Street address (including apt. no.)$5Section 199A dividends $6Investment expensesReduction Act$$the IRS. If you are$$requirement for 2021 tax returns. If those regulations are issued andor agency, or legal residence inaddressReduction Actthe case of an individual, is City or town, state or province, country, and ZIP or foreign postal code $7Foreign tax paid8Foreign country or U.S. possession Notice, see the$7Foreign tax paid8Foreign country or U.S. possession return, a negligence$7Foreign tax paid8Foreign country or U.S. possession an article at www.irs.gov/Form1099 explaining the change. Untillocated in Internal Revenue ServiceDWMRSNotice, see the 2021 Generalpenalty or otherregulations are issued, however, the number remains at 250, aspart F in theAlabama, Arizona, Arkansas, Delaware, 2021 General 9Cash liquidation distributions10 Noncash liquidation distributions Instructions for Certain9Cash liquidation distributions10 Noncash liquidation distributionsimposed on you if9Cash liquidation distributions10 Noncash liquidation distributionsInstructions for CertainFlorida, Georgia, Kentucky, Maine,Austin Submission Processing Center sanction may be2021 General Instructions for Certain Information Returns.Information this income is taxableInformationMassachusetts, Mississippi, NewP.O. Box 149213 and the IRS $$Returns.$$determines that it has$$of the number of returns. Hampshire, New Jersey, New Mexico,Austin, TX 78714Returns.New York, North Carolina, Ohio, Texas, 11Exempt-interest dividends12bond interest dividends requirement 11Exempt-interest dividends12bond interest dividends not been reported.requirement 11Exempt-interest dividends12bond interest dividends Who must le.Vermont, Virginiarequirement$$$$$$ Account number (see instructions)2nd TIN not. 13State 1415State tax withheld Account number (see instructions)13State 1415State tax withheld Account number (see instructions)2nd TIN not. 13State 1415State tax withheld$$$ $$$For more information and the Privacy Act and Paperwork Reduction Act Notice,L1096 41-0852411 5100 Form1096(2021)see the 2021 General Instructions for Certain Information Returns.Form1099-DIVLDA 41-0852411 5130 www.irs.gov/Form1099DIV Department of the Treasury - Internal Revenue ServiceForm1099-DIVLDB (keep for your records)5131 www.irs.gov/Form1099DIV Department of the Treasury - Internal Revenue ServiceForm1099-DIVLDC 5132 www.irs.gov/Form1099DIV Department of the Treasury - Internal Revenue ServiceAPEX 1099R PACKAGED LASER SETAPEX LRA APEX LRB APEX LRCLR2 APEX LRD1 APEX L10969898 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, Pensions, Annuities, country, 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, (Rev. February 2021)$ 2aTaxable amount Retirement or$ 2aTaxable amount Retirement or$ 2aTaxable amount Retirement or$ 2aTaxable amount Department of the TreasuryU.S. Information Returns 2021Retirement or 2021 Prot-Sharing Plans,2021 Prot-Sharing Plans,2021 Prot-Sharing Plans,2021 Internal Revenue ServiceProt-Sharing Plans, IRAs, InsuranceIRAs, InsuranceIRAs, InsuranceIRAs, Insurance $ Form 1099-R Contracts, etc. $ Form 1099-R Contracts, etc. $ Form 1099-R Contracts, etc. $ Form 1099-R FILERS nameContracts, etc.PAYERS TIN RECIPIENTS TIN 2bTaxable amount4 TotalPAYERS TINCopy ARECIPIENTS TIN 2bnot determined 4 TotalPAYERS TINCopyBRECIPIENTS TIN 2bTaxable amount4 TotalPAYERS TINCopy CRECIPIENTS TIN 2bTaxable amount4 TotalCopy D Taxable amount not determined distribution For3Capital gain (included indistribution Report thisnot determined distribution For Recipient'snot determined distribution Street address (including room or suite number)3Capital gain (included inFederal 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,l$ $File with Form 1096. $ $ form shows$ $ 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 Rothappreciation inFor Privacy ActDesignated Rothappreciation infederal incomeDesignated RothNet unrealized Designated RothName of person to contactRECIPIENTS name 5Employee contributions/ 6Net unrealizedRECIPIENTS name, stret adres, city or town, state or province, country and ZIP or foreign postal code 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 contributions orNet unrealized For Privacy ActFax numbercontributions oremployers securities and Paperworkcontributions oremployers securities tax withheld incontributions oremployers securities insurance premiums employers securities and Paperwork insurance premiums Reduction Actinsurance premiums box 4, attachinsurance premiums Email address Reduction Act $ code(s) IRA/ $ 8Other Notice, see the$ 7DistributionSEP/ $ 8Other this copy to$ 7DistributionIRA/ $ 8Other This information is$ 7DistributionSEP/ $ 8Other 1 2021 General2 Social security number 3 Total number of forms $ 4 Federal income tax withheld $ 5 Total amount reported with this Form 1096Street address (including apt. no.) 7DistributionSEP/2021 Generalcode(s) IRA/ your return.code(s) SEP/ code(s) IRA/ Notice, see theInstructions forSIMPLE $ % Instructions for CertainSIMPLE $ % This information isSIMPLE $ % SIMPLE $ 6 % 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 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 %$ being furnished to the IRS. distribution % distribution %$ W-2G 1097-BTC1098 78 84 03 74 83 80 79 85 73 91 86 92 10 1632 Returns.8110Amount 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.$ $ $$ $ $ $ $ $ $ $ $ $ $ 1099-LTC1099-MISC 1099-NEC 1099-OID1099- 1099-Q1099-QA 1099-R1099-S1099-SA 1099-SB 3921392254985498-ESA5498-QA 5498-SA 93 $ 19Local distribution 96 PATR31 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 71 9719Local distribution 19Local distribution 19Local distributionpayment$ $ payment$ $ payment$ $ payment$ $$ $ $ $ $ $ $ $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 ServiceForm 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. 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.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, country, 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,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 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 electronicallyForms 1097, 1098, 1099, 3921, 3922, 5498, or W-2G.When to le. File Form 1096 as follows.PAYERS TIN RECIPIENTS TIN 2bTaxable amount4 TotalPAYERS TINCopy ARECIPIENTS TIN 2bTaxable amount4 TotalPAYERS TINCopyBRECIPIENTS TIN 2bnot determined 4 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 thisTaxable amountdistribution For Recipient'sTaxable amountdistribution Copy D the FIRE System. See Pub. 1220. 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 For Payer Purpose of form. Use this form to transmit paper Forms 1097, 1098, return. If thisor Locatl Tax State,anCity,lbox 2a) withheld Service Centerbox 2a) withheld federal taxbox 2a) withheld State,City, box 2a) withheld Caution:r d/or Where To File1099, 3921, 3922, 5498, and W-2G to the IRS. $ $File with Form 1096. $ $ form shows$ $ Tax Departmen 2 $ $ LocatDepoartmenorCopy electronically but fail to do so, and you do not have an approved RECIPIENTS name, stret adres, city or town, state or province, country and ZIP or foreign postal code waiver, you may be subject to a penalty. The Taxpayer First Act of RECIPIENTS name 5Employee contributions/ 6Net unrealized RECIPIENTS name, stret adres, city or town, state or province, country and ZIP or foreign postal code 5Employee contributions/ 6Net unrealizedfederal income5Employee contributions/ 6Net unrealizedRECIPIENTS name, stret adres, city or town, state or province, country and ZIP or foreign postal code 5Employee contributions/ 6Net unrealized2019, enacted July 1, 2019, authorized the Department of thefollowing.Designated Rothappreciation in For Privacy Actcontributions orappreciation intax withheld inDesignated Rothappreciation incontributions oremployers securities For Privacy ActIf your principal business, ofceUse the following Designated RothDesignated Rothappreciation in contributions oremployers securities and Paperworkinsurance premiums employers securities box 4, attachcontributions oremployers securities insurance premiums Treasury and the IRS to issue regulations that reduce the 250-returnor agency, or legal residence inaddressand Paperwork insurance premiums Reduction Actthis copy to$ insurance premiums $ $ $ 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.7DistributionSEP/ 8Other This information is7DistributionSEP/ 8Other Notice, see thelocated inDistribution 2021 GeneralIRA/ IRA/ an article at www.irs.gov/Form1099 explaining the change. Until2021 General Street address (including apt. no.) 7code(s) SEP/ Instructions forcode(s) SEP/ This information iscode(s) SIMPLE $ % code(s) SIMPLE $ regulations are issued, however, the number remains at 250, aspart F in theAlabama, Arizona, Arkansas, Delaware,Internal Revenue Service SIMPLE CertainSIMPLE $ % % Instructions for Florida, Georgia, Kentucky, Maine,Austin Submission Processing Center Certain 2021 General Instructions for Certain Information Returns.City or town, state or province, country, and ZIP or foreign postal code9aYour percentage of total$ % Information9aYour percentage of total 9bTotal employee contributions 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 %$ 9bTotal employee contributions Returns. distribution %$ being furnished to the IRS. distribution %$ distribution %$ Who must le.Returns. Hampshire, New Jersey, New Mexico,Austin, TX 78714of the number of returns. New York, North Carolina, Ohio, Texas, 16State distribution State/Payers state no.16State distribution 16State distribution 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 15 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 Service3 Transmittal 1096 forms are included with each setAPEX 1099-DIV PACKAGED LASER SETAPEX 1099-R PACKAGED LASER SET PARTS PARTSSTANDARD SETS 50 sheets for 100 Recipients STANDARD SETS 50 sheets for 100 Recipients959333 PART SET includes: 50 Sheets EA Laser 1099DIV Copy A, B, C 959444 PART SET includes: 50 Sheets EA Laser 1099R Copy A, B, C, D959344 PART SET includes: 50 Sheets EA Laser 1099DIV Copy A, B, C, C 959466 Part set includes: 50 Sheets EA Laser 1099R Copy A, B, C, D, 1, 2STANDARD SETS W/Envelopes 50 Sheets for 100 Recipients STANDARD SETS W/Envelopes 50 Sheets for 100 Recipients95933E3 PART SET includes: 50 Sheets EA Laser 1099DIV Copy A, B, C95944E4 PART SET includes: 50 Sheets EA Laser 1099R Copy A, B, C, D + 100 DWMR + 100 DWMR95934E4 PART SET includes: 50 Sheets EA Laser 1099DIV Copy A, B, C, C95946E6 Part set includes: 50 Sheets EA Laser 1099R Copy A, B, C, D, 1, 2 + 100 DWMR + 100 DWMRVALUE SETS W/Self-Seal Envelopes 10 Sheets for 20 Recipients95910ES4 PART SET includes: 10 Sheets EA Laser 1099DIV Copy A, B, C, C + 20 DWMR44"