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2021 Form 1099-R Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs,
Insurance Contracts, etc.
OMB No. 1545-0119
Copy B: Report this income on your Federal tax return. If this form Date: 01/13/2022 Document ID: 32F2 54J 4W61
shows Federal income tax withheld on line 4, attach this copy to your Account number: 48056302
return. This information is being furnished to the Internal Revenue Service.
RECIPIENT'S TIN: XXX-XX-9739 PAYER'S TIN: 23-2869268
Recipient: WILLIAM D ARMES Phone number: (800) 662-2739
IRA VFTC AS CUSTODIAN Payer: VANGUARD FIDUCIARY TRUST COMPANY
ROLLOVER ACCOUNT VANGUARD BROKERAGE
461 KAKKIS DR UNIT 102 P.O. BOX 982901
LONG BEACH, CA 90803-6374 EL PASO, TX 79998-2901
1 Gross distribution $9,500.00 9a Your percentage of total distribution %
2a Taxable amount $9,500.00 9b Total employee contributions
2b Taxable amount not determined (X) 10 Amount allocable to IRR within 5 years
Total distribution ( ) 11 1st year of desig. Roth contrib.
3 Capital gain (included on line 2a) 12 FATCA filing requirement ( )
4 Federal income tax withheld 13 Date of Payment
5 Employee/Desig Roth Contribs or Insur 14 State tax withheld
Premiums 15 State
6 Net unrealized appreciation in employer's Payer's state number
securities 16 State distribution
7 Distribution code(s) 7 17 Local tax withheld
IRA/SEP/SIMPLE (X) 18 Name of locality
8 Other amount 19 Local distribution
Other amount percentage %
2021 Form 1099-R Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs,
Insurance Contracts, etc. OMB No. 1545-0119
Copy 2: File this copy with your state, city, or local income tax return, Date: 01/13/2022 Document ID: 32F2 54J 4W61
when required. Account number: 48056302
RECIPIENT'S TIN: XXX-XX-9739 PAYER'S TIN: 23-2869268
Recipient: WILLIAM D ARMES Phone number: (800) 662-2739
IRA VFTC AS CUSTODIAN Payer: VANGUARD FIDUCIARY TRUST COMPANY
ROLLOVER ACCOUNT VANGUARD BROKERAGE
461 KAKKIS DR UNIT 102 P.O. BOX 982901
LONG BEACH, CA 90803-6374 EL PASO, TX 79998-2901
1 Gross distribution $9,500.00 9a Your percentage of total distribution %
2a Taxable amount $9,500.00 9b Total employee contributions
2b Taxable amount not determined (X) 10 Amount allocable to IRR within 5 years
Total distribution ( ) 11 1st year of desig. Roth contrib.
3 Capital gain (included on line 2a) 12 FATCA filing requirement ( )
4 Federal income tax withheld 13 Date of Payment
5 Employee/Desig Roth Contribs or Insur 14 State tax withheld
Premiums 15 State
6 Net unrealized appreciation in employer's Payer's state number
securities 16 State distribution
7 Distribution code(s) 7 17 Local tax withheld
IRA/SEP/SIMPLE (X) 18 Name of locality
8 Other amount 19 Local distribution
Other amount percentage %
