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099001173094
Box B Payer’sfederalidentificationnumber
Box 1 Grossdistribution
.00Box 2a Taxableamount
.00
Box 2b Taxableamountnotdetermined
Box 1 Grossdistribution
.00Box 2a Taxableamount
.00
Box 2b Taxableamountnotdetermined
IT-1099-R
Box 3 Capital gain (included in box 2a)
.00Box 7 Distributioncode(s)
Box 9a Percentageofdistribution
Box 9b Employeecontributions
.00Box 10 AmountallocabletoIRRwithin5years
.00
Box 3 Capital gain (included in box 2a)
.00Box 7 Distributioncode(s)
Box 9a Percentageofdistribution
Box 9b Employeecontributions
.00Box 10 AmountallocabletoIRRwithin5years
.00
1099-R Record 1
1099-R Record 2
DepartmentofTaxationandFinance
Summary of Federal Form 1099-R StatementsNew York State • New York City • Yonkers
Do not detach or separatethe1099-RRecordsbelow.FileFormIT-1099-Rasanentirepage.Seeinstructionsontheback.
Name(s)asshownonreturn
Box A Payer’snameandfulladdress
Box C Accountnumber
Box C Accountnumber
Box A Payer’snameandfulladdress
Box B Payer’sfederalidentificationnumber
Corrected (1099-R)
Corrected (1099-R)
Recipient’s identification number for this 1099-R ..................
Recipient’s identification number for this 1099-R ..................
Do not detach.
Totaldistribution.......................
Totaldistribution.......................
Box 14 Statedistribution
.00 Box 15 Localtaxwithheld(NYCorYonkers)
.00 .00 Box 16 Localityname
Box 17 Localdistribution
.00 .00
Box 14 Statedistribution
.00 Box 15 Localtaxwithheld(NYCorYonkers)
.00 .00 Box 16 Localityname
Box 17 Localdistribution
.00 .00
NYState
NYState
Localitya
Localityb
Localitya
Localityb
Localitya
Localityb
Localitya
Localityb
Localitya
Localityb
Localitya
Localityb
State Box 12 Statetaxwithheld(forNYState)
.00
State Box 12 Statetaxwithheld(forNYState)
.00
N Y
N Y
Box 11 1styearofdesig.Rothcontrib.
Box 11 1styearofdesig.Rothcontrib.
Identifyingnumberasshownonreturn
099002173094
IT-1099-R(2017)(back)
General instructionsWho must file this form –YoumustcompleteFormIT-1099-R,ifyoufileaNewYorkStateincometaxreturnandyoureceived1099-RstatementsthatshowNewYorkState,NewYorkCity,orYonkerswithholding.
Specific instructionsEnterthename(s)andentire9-digitsocialsecuritynumber(SSN)oremployeridentificationnumber(EIN)asenteredonyourincometaxreturn.Ifyouaremarriedfilingajointreturn,enterbothnamesandtheSSNlistedfirstonthereturn.
Entering whole dollar amounts –Whenenteringamounts,enter whole dollar amounts only(zeroshavebeenpreprinted).Usethefollowingroundingruleswhenenteringyouramounts;dropamountsbelow50centsandincreaseamountsfrom50to99centstothenextdollar.Forexample,$1.39becomes$1and$2.50becomes$3.
Completeone1099-R RecordsectionforeachfederalForm1099-Ryou(andiffilingjointly,yourspouse),oranestateortrustreceivedthatshowsNewYorkState,NewYorkCity,orYonkerswithholding.EnteronlytheinformationrequestedonFormIT-1099-R.CompleteadditionalForm(s)IT-1099-Rifnecessary.
How to complete each 1099-R RecordEachboxinthe1099-R RecordsectioncorrespondstoanumberedboxonfederalForm1099-R.Entertheamount,code,ordescriptionprovidedonfederalForm1099-RinthecorrespondingnumberedboxesonFormIT-1099-R.
Recipient’s identification number for this Form 1099-R – EnteryourSSN(oryourspouse’sSSN)ortheEINoftheestateortrust,asapplicable.
InBox A and Box B,enterthepayer’snameandaddressandthepayer’sfederalidentificationnumberastheyappearonthecorrespondingfederalForm1099-R.
MarkanXintheTotal distributionboxofthe1099-R Record if thecorrespondingboxonfederalForm1099-Rismarked.
Corrected (1099-R) –Ifthe1099-R RecordisforafederalcorrectedForm1099-R,markanXintheCorrected (1099-R) box.
Transferthetaxwithheldamountstoyourincometaxreturn.IncludethetotalNYStaxwithheldamounts,thetotalNYCtaxwithheldamounts,andthetotalYonkerstaxwithheldamountsfromallyourForm(s)IT-1099-Rasfollows:• NYS tax withheld –IncludeonFormIT-201,line72;FormIT-203,line62;orFormIT-205,line34.
• NYC tax withheld –IncludeonFormIT-201,line73;FormIT-203,line63;orFormIT-205,line35.
• Yonkers tax withheld –IncludeonFormIT-201,line74;FormIT-203,line64;orFormIT-205,line36.
Do not detach or separatethe1099-RRecords.FileFormIT-1099-Rasanentirepage.Submitthisform(IT-1099-R)withyourNewYorkStateincometaxreturn:FormIT-201,IT-203,orIT-205.SubmitadditionalForm(s)IT-1099-Rifapplicable.
Do notsubmityourfederal1099-Rforms;keepthemforyourrecords.
InstructionsDo not detach.
Box 1 Grossdistribution
.00Box 2a Taxableamount
.00
Box 2b Taxableamountnotdetermined
Box 3 Capital gain (included in box 2a)
.00Box 7 Distributioncode(s)
Box 9a Percentageofdistribution
Box 9b Employeecontributions
.00Box 10 AmountallocabletoIRRwithin5years
.00
1099-R Record 3
Box A Payer’snameandfulladdress
Box B Payer’sfederalidentificationnumber
Corrected (1099-R)Recipient’s identification number for this 1099-R ..................
Totaldistribution.......................
Box 14 Statedistribution
.00 Box 15 Localtaxwithheld(NYCorYonkers)
.00 .00 Box 16 Localityname
Box 17 Localdistribution
.00 .00
NYState
Localitya
Localityb
Localitya
Localityb
Localitya
Localityb
State Box 12 Statetaxwithheld(forNYState)
.00N Y
Box 11 1styearofdesig.Rothcontrib.
Box C Accountnumber