PAYERS name, street address, cty or town, state or province,cOuntry, ZIP or forelgn postal code, and telaphone no$.$CAPITAL PENSION FUND$344$ WEST MAIN STREETYOUR CITY, YS XXXXXXXX$555-2323$PAYERS TIN$09-4021915$RECIPIENTS nameHARRY FORD$4343$ DAISY WAYStreet address ncluding apt. no$)10$ Amount aliocatble to IRRwthin $5$yrs$457676$RECIPIENT'S TINAooou number $($see instructions$)$Form $1099-$R$402-00-9195$S$42000$is tavabieHarry is subect to a f$05\%$ additional taxCORRECTED $($ checked$)1$ Gross distributionNone of Harry's stribution is tavabieMarkk for follow ups $42,000\mathrm{.}0013$ Date ofpayrmet$2$a Touable amOuntwww.irEGOVFOn$1099$R$2$b Taxable arnountnot determined$7$ Distritbutioncode$($s$)7$City or tow, ste or provinoe, coutry, and ZP or foreign postal code Ba Your percentage of total$9$b Tota employes contibutionsYOUR cITY. YS XXXXXdistribution$111$s year df desig $12$ FATCA fling$14$ State tax withheldRoth oortrio.roquiromentOMB No$.1545-01193$ Capital gain $($included in$4$ Federal income taxbox $2$a$)17$ Local tax withheldThe taxabie distribution is figured using the Simpified hMeth od Worksheet$2022$SEP$/$SIMPLEForm $1089-$RTotaldistribution$5$ Employoe contibutions$/6$ Not unrcalizodDesignated Rothcontributions orinsuranoe premiumswithheid$5,200\mathrm{.}00$appreciation inemployer's socurities$8$ Other$9\%$$ $89,000\mathrm{.}0015$ State$/$Payer$\text{'}$s state no$.$YS$/18$ Name of localityDistrbutions FronmPensions, Annultles,Retdrement orProfit$-$Sharing Plans,IRAS, InsuranceContracts, etc.Copy BReport thisincome on yourfederal taxreturn. If thisform showsfederal incometax withheld inbox $4,$ attachthis copy toyour return.This information isbeing furnished tothe IRS$16$ State distribution$19$ Locai distributionDepartment of the Troasury$-$ Intornal Rgvenue Sarvoe