Page 18 - Income Documentation

PAYER'S name, street address, city, state, and ZIP code 1 Gross distribution 2a Taxable amount OMB No. 1545-0119
National Financial Services LLC as agent for 2021
FIDELITY INVESTMENTS $ 1,000.00 $ 1,000.00
Form 1099-R:
P.O. Box 28019 2b Taxable amount Total Distributions From

Albuquerque, NM 87125-8019 not determined X distribution Pensions, Annuities,
3 Capital gain 4 Federal income tax Retirement or
(Included in box 2a) withheld Profit-Sharing Plans,
IRAs, Insurance
$ $ Contracts, etc.
eDelivered
5 Employee contributions/ 6 Net unrealized appreciation This information is
RECIPIENT'S Name and Address Designated Roth contrib. in employer's securities being furnished to
or insurance premiums the Internal Revenue
$ $ Service.
WILLIAM DAVID ARMES 7 Distribution IRA/ 8 Other
461 KAKKIS DR UNIT 102 code(s) SEP/ COPY C
LONG BEACH CA 90803-6374 SIMPLE
7 X $ %
For
9a Your percentage of 9b Total employee contributions
total distribution Recipient's
Records
% $
14 State tax withheld 15 State/Payer's state no. 16 State distribution
$ CA-804-9168-1
Customer service phone number 800-544-6666 $
PAYER'S TIN RECIPIENT'S TIN Account Number 17 Local tax withheld 18 Name of locality 19 Local distribution
04-3523567 ***-**-9739 164-405418-001 $ $
FORM 1099-R Department of the Treasury - Internal Revenue Service
PAYER'S name, street address, city, state, and ZIP code 1 Gross distribution 2a Taxable amount OMB No. 1545-0119
National Financial Services LLC as agent for 2021
FIDELITY INVESTMENTS $ 1,000.00 $ 1,000.00
Form 1099-R:
P.O. Box 28019 2b Taxable amount X Total Distributions From
Albuquerque, NM 87125-8019
not determined distribution Pensions, Annuities,
3 Capital gain 4 Federal income tax Retirement or
(Included in box 2a) withheld Profit-Sharing Plans,
IRAs, Insurance
$ $
Contracts, etc.
eDelivered 5 Employee contributions/ This information is
RECIPIENT'S Name and Address Designated Roth contrib. 6 Net unrealized appreciation being furnished to
in employer's securities
or insurance premiums the Internal Revenue
$ $ Service.
WILLIAM DAVID ARMES 7 Distribution IRA/ 8 Other
461 KAKKIS DR UNIT 102 code(s) SEP/ COPY 2
LONG BEACH CA 90803-6374 SIMPLE
7 X $ % File this copy with
9a Your percentage of 9b Total employee contributions your state, city, or
total distribution local income tax
return, when
% $ required.
14 State tax withheld 15 State/Payer's state no. 16 State distribution
$ CA-804-9168-1
Customer service phone number 800-544-6666 $
PAYER'S TIN RECIPIENT'S TIN Account Number 17 Local tax withheld 18 Name of locality 19 Local distribution
04-3523567 ***-**-9739 164-405418-001 $ $
FORM 1099-R Department of the Treasury - Internal Revenue Service

PAYER'S name, street address, city, state, and ZIP code 1 Gross distribution 2a Taxable amount
OMB No. 1545-0119
National Financial Services LLC as agent for 2021
FIDELITY INVESTMENTS $ 1,000.00 $ 1,000.00 Form 1099-R:
P.O. Box 28019 2b Taxable amount Total Distributions From

Albuquerque, NM 87125-8019 not determined X distribution Pensions, Annuities,
3 Capital gain 4 Federal income tax Retirement or
(Included in box 2a) withheld Profit-Sharing Plans,
IRAs, Insurance
$ $ Contracts, etc.
eDelivered
5 Employee contributions/ 6 Net unrealized appreciation This information is
RECIPIENT'S Name and Address Designated Roth contrib. in employer's securities being furnished to
or insurance premiums the Internal Revenue
$ $ Service.
WILLIAM DAVID ARMES 7 Distribution IRA/ 8 Other
461 KAKKIS DR UNIT 102 code(s) SEP/ COPY B
LONG BEACH CA 90803-6374 SIMPLE Report this income on
7 X $ % your federal tax return.
If this Form shows
9a Your percentage of 9b Total employee contributions federal income tax
total distribution withheld in box 4,
attach this copy to
% $ your return.
14 State tax withheld 15 State/Payer's state no. 16 State distribution
$ CA-804-9168-1
Customer service phone number 800-544-6666 $
PAYER'S TIN RECIPIENT'S TIN Account Number 17 Local tax withheld 18 Name of locality 19 Local distribution
04-3523567 ***-**-9739 164-405418-001 $ $
FORM 1099-R Department of the Treasury - Internal Revenue Service
01/14/2022 eDelivered