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099001173094 Box B Payer’s federal identification number Box 1 Gross distribution .00 Box 2a Taxable amount .00 Box 2b Taxable amount not determined Box 1 Gross distribution .00 Box 2a Taxable amount .00 Box 2b Taxable amount not determined IT-1099-R Box 3 Capital gain (included in box 2a) .00 Box 7 Distribution code(s) Box 9a Percentage of distribution Box 9b Employee contributions .00 Box 10 Amount allocable to IRR within 5 years .00 Box 3 Capital gain (included in box 2a) .00 Box 7 Distribution code(s) Box 9a Percentage of distribution Box 9b Employee contributions .00 Box 10 Amount allocable to IRR within 5 years .00 1099-R Record 1 1099-R Record 2 Department of Taxation and Finance Summary of Federal Form 1099-R Statements New York State • New York City • Yonkers Do not detach or separate the 1099-R Records below. File Form IT-1099-R as an entire page. See instructions on the back. Name(s) as shown on return Box A Payer’s name and full address Box C Account number Box C Account number Box A Payer’s name and full address Box B Payer’s federal identification number 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. Total distribution....................... Total distribution....................... Box 14 State distribution .00 Box 15 Local tax withheld (NYC or Yonkers) .00 .00 Box 16 Locality name Box 17 Local distribution .00 .00 Box 14 State distribution .00 Box 15 Local tax withheld (NYC or Yonkers) .00 .00 Box 16 Locality name Box 17 Local distribution .00 .00 NY State NY State Locality a Locality b Locality a Locality b Locality a Locality b Locality a Locality b Locality a Locality b Locality a Locality b State Box 12 State tax withheld (for NY State) .00 State Box 12 State tax withheld (for NY State) .00 NY NY Box 11 1st year of desig. Roth contrib. Box 11 1st year of desig. Roth contrib. Identifying number as shown on return

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Page 1: Form IT-1099-R:2017:Summary of Federal Form 1099-R ... · Summary of Federal Form 1099-R Statements New York State • New York City • Yonkers Do not detach or separate the 1099-R

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

Page 2: Form IT-1099-R:2017:Summary of Federal Form 1099-R ... · Summary of Federal Form 1099-R Statements New York State • New York City • Yonkers Do not detach or separate the 1099-R

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


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