Box
Copy B: Report this income on your federal tax return. If this form shows federal income tax withheld in box 4,
attach this copy to your return.
1 Gross distribution 5,050.00
2a Taxable amount 5,050.00
2b Taxable amount not determined
Total Distribution
3 Capital gains (included in box 2a)
4 Federal income tax withheld
5 Employee contributions/Designated Roth contributions or
insurance premiums
6 Net unrealized appreciation in employers securities
7 Distribution codes 7
IRA/SEP/SIMPLE [X]
