STATE STREET RETIREE SERVICES FOR

BOEING FINANCIAL BENEFITS SERVICE CENTER

P.O. BOX 28021
ALBUQUERQUE NM 87125−8021
62128−T0

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BILLY L DUNSWORTH
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9125 E G ST
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TACOMA WA 98445−2153

1099−R Instructions for Recipient Box 5. Generally, this shows the employee’s investment in the contract (after−tax contributions), if any,
Generally, distributions from retirement plans (IRAs, qualified plans, section 403(b) plans, and governmental recovered tax free this year; the portion that’s your basis in a designated Roth account; the part of
section 457(b) plans), insurance contracts, etc., are reported to recipients on Form 1099−R. premiums paid on commercial annuities or insurance contracts recovered tax free; the nontaxable part of a
Qualified plans and section 403(b) plans. If your annuity starting date is after 1997, you must use the charitable gift annuity; or the investment in a life insurance contract reportable under section 6050Y. This
simplified method to figure your taxable amount if your payer didn’t show the taxable amount in box 2a. box doesn’t show any IRA contributions. If the amount shown is your basis in a designated Roth account,
See the instructions for your tax return. the year you first made contributions to that account may be entered in box 11.
IRAs. For distributions from a traditional individual retirement arrangement (IRA), simplified employee Box 6. If you received a lump−sum distribution from a qualified plan that includes securities of the
pension (SEP), or savings incentive match plan for employees (SIMPLE), generally the payer isn’t required to employer’s company, the net unrealized appreciation (NUA) (any increase in value of such securities while
compute the taxable amount. See the instructions for your tax return to determine the taxable amount. If in the trust) is taxed only when you sell the securities unless you choose to include it in your gross income
you’re at least age 72, you must take minimum distributions from this year. See Pub. 575 and Form 4972. If you roll over the distribution to a designated Roth account in the
your IRA (other than a Roth IRA). If you don’t, you’re subject to a 50% excise tax on same plan or to a Roth IRA, see the instructions for box 2a. For a direct rollover to a designated Roth
the amount that should’ve been distributed. See Pub. 590−A and Pub. 590−B for more information on IRAs. account in the same plan or to a Roth IRA, the NUA is included in box 2a. If you didn’t receive a lump−sum
Roth IRAs. For distributions from a Roth IRA, generally the payer isn’t required to compute the taxable distribution, the amount shown is the NUA attributable to employee contributions, which isn’t taxed until
amount. You must compute any taxable amount on Form 8606. An amount shown in box 2a may be you sell the securities.
taxable earnings on an excess contribution. Box 7. The following codes identify the distribution you received. For more information on these
Loans treated as distributions. If you borrow money from a qualified plan, section 403(b) plan, or distributions, see the instructions for your tax return. Also, certain distributions may be subject to an
governmental section 457(b) plan, you may have to treat the loan as a distribution and include all or part of additional 10% tax. See the Instructions for Form 5329.
the amount borrowed in your income. There are exceptions to this rule. If your loan is taxable, code L will 1 − Early distribution, no known exception (in most cases, under age 59 1/2). 2 − Early distribution,
be shown in box 7. See Pub. 575. exception applies (under age 59 1/2). 3 − Disability. 4 − Death. 5 − Prohibited transaction.
Recipient’s taxpayer identification number (TIN). For your protection, this form may show only the last four 6 − Section 1035 exchange (a tax−free exchange of life insurance, annuity, qualified long−term care
digits of your TIN (SSN, ITIN, ATIN, or EIN). However, the payer has reported your complete TIN to the IRS. insurance, or endowment contracts). 7 − Normal distribution. 8 − Excess contributions plus
Account number. May show an account, policy, or other unique number the payer assigned to distinguish earnings/excess deferrals (and/or earnings) taxable in 2022. 9 − Cost of current life insurance
your account. protection. A − May be eligible for 10−year tax option (see Form 4972). B − Designated Roth account
Box 1. Shows the total amount distributed this year. The amount may have been a direct rollover, a distribution. Note: If code B is in box 7 and an amount is reported in box 11, see the Instructions for
transfer or conversion to a Roth IRA, a recharacterized IRA contribution; or you may have received it as Form 5329. C − Reportable death benefits under section 6050Y. D − Annuity payments from
periodic payments, nonperiodic payments, or a total distribution. nonqualified annuities that may be subject to tax under section 1411. E − Distributions
Report the amount on Form 1040, 1040−SR, or 1040−NR on the line for "IRA distributions" or "Pensions and under Employee Plans Compliance Resolution System (EPCRS). F − Charitable gift annuity.
annuities" (or the line for "Taxable amount") and on Form 8606, as applicable. However, if this is a lump−sum G − Direct rollover of a distribution to a qualified plan, a section 403(b) plan, a governmental
distribution, see Form 4972. If you haven’t reached minimum retirement age, report your disability section 457(b) plan, or an IRA. H − Direct rollover of a designated Roth account distribution to
payments on the line for "Wages, salaries, tips, etc." on your tax return. Also report on that line permissible a Roth IRA. J − Early distribution from a Roth IRA, no known exception (in most cases,
withdrawals from eligible automatic contribution arrangements and corrective distributions of excess under age 59 1/2). K − Distribution of traditional IRA assets not having a readily available FMV.
deferrals, excess contributions, or excess aggregate contributions except if the distribution is of designated L − Loans treated as distributions. M − Qualified plan loan offset.
Roth contributions or your after−tax contributions or if you’re self−employed. If a life insurance, N − Recharacterized IRA contribution made for 2022 and recharacterized in 2022.
annuity, qualified long−term care, or endowment contract was transferred tax free to another trustee or P − Excess contributions plus earnings/excess deferrals (and/or earnings) taxable in 2021.
contract issuer, an amount will be shown in this box and code 6 will be shown in box 7. If a charge or Q − Qualified distribution from a Roth IRA. R − Recharacterized IRA contribution made for 2021
payment was made against the cash value of an annuity contract or the cash surrender value of a life and recharacterized in 2022. S − Early distribution from a SIMPLE IRA in first 2 years,
insurance contract for the purchase of qualified long−term care insurance, an amount will be shown in this no known exception (under age 59 1/2). T − Roth IRA distribution, exception applies.
box and code W will be shown in box 7. You need not report these amounts on your tax return. If code C is U − Dividend distribution from ESOP under section 404(k). Note: This distribution
shown in box 7, the amount shown in box 1 is a receipt of reportable death benefits that is taxable in part. isn’t eligible for rollover. W − Charges or payments for purchasing qualified long−term care insurance
Box 2a. This part of the distribution is generally taxable. If there is no entry in this box, the payer may not contracts under combined arrangements. If the IRA/SEP/SIMPLE box is checked, you’ve received a
have all the facts needed to figure the taxable amount. In that case, the first box in box 2b should be traditional IRA, SEP, or SIMPLE distribution.
checked. You may want to get one of the free publications from the IRS to help you figure the taxable Box 8. If you received an annuity contract as part of a distribution, the value of the contract is shown. It
amount. See Additional information on the back of Copy 2. For an IRA distribution, see IRAs and Roth isn’t taxable when you receive it and shouldn’t be included in boxes 1 and 2a. When you receive periodic
IRAs, earlier. payments from the annuity contract, they’re taxable at that time. If the distribution is made to more than
For a direct rollover, other than from a qualified plan, section 403(b) plan, or governmental section 457(b) plan to one person, the percentage of the annuity contract distributed to you is also shown. You’ll need this
a designated Roth account in the same plan or to a Roth IRA, zero should be shown and you must enter information if you use the 10−year tax option (Form 4972). If charges were made for qualified long−term
zero (−0−) on the "Taxable amount" line of your tax return. If you roll over a distribution (other than a care insurance contracts under combined arrangements, the amount of the reduction in the investment (but
distribution from a designated Roth account) from a qualified plan, section 403(b) plan, or governmental section not below zero) in the annuity or life insurance contract is reported here.
457(b) plan to a designated Roth account in the same plan or to a Roth IRA, you must include on the Box 9a. If a total distribution was made to more than one person, the percentage you received is shown.
"Taxable amount" line of your tax return the amount shown in this box plus the amount in box 6, if any. Box 9b. For a life annuity from a qualified plan or from a section 403(b) plan (with after−tax contributions),
If this is a total distribution from a qualified plan and you were born before January 2, 1936 (or you’re the an amount may be shown for the employee’s total investment in the contract. It is used to compute the
beneficiary of someone born before January 2, 1936), you may be eligible for the 10−year tax option. See taxable part of the distribution. See Pub. 575.
the Form 4972 instructions for more information. Box 10. If an amount is reported in this box, see the Instructions for Form 5329 and Pub. 575.
If you’re an eligible retired public safety officer who elected to exclude from income distributions from your Box 11. The first year you made a contribution to the designated Roth account reported on this form is
eligible plan used to pay certain insurance premiums, the amount shown in box 2a hasn’t been reduced by shown in this box.
the exclusion amount. See the instructions for your tax return for more information. Box 12. If checked, the payer is reporting on this Form 1099 to satisfy its Internal Revenue Code
Box 2b. If the first box is checked, the payer was unable to determine the taxable amount and box 2a chapter 4 account reporting requirement under FATCA.
should be blank, except for an IRA. It’s your responsibility to determine the taxable amount. If the second box You may also have a filing requirement. See the Instructions for Form 8938.
is checked, the distribution was a total distribution that closed out your account. Box 13. Shows the date of payment for reportable death benefits under section 6050Y.
Box 3. If you received a lump−sum distribution from a qualified plan and were born before January 2, 1936 Boxes 14−19. If state or local income tax was withheld from the distribution, boxes 16 and 19 may show
(or you’re the beneficiary of someone born before January 2, 1936), you may be able to elect to treat this the part of the distribution subject to state and/or local tax.
amount as a capital gain on Form 4972 (not on Schedule D (Form 1040)). See the Form Additional information. You may want to see: Form W−4P, Form 4972, Form 5329, Form 8606
4972 instructions. For a charitable gift annuity, report as a long−term capital gain as explained in the Pub. 525, Taxable and Nontaxable Income Pub. 560, Retirement Plans for Small Business Pub. 571,
Instructions for Form 8949. Tax−Sheltered Annuity Plans Pub. 575, Pension and Annuity Income Pub. 590−A, Contributions to IRAs
Box 4. Shows federal income tax withheld. Include this amount on your income tax return as tax withheld, Pub. 590−B, Distributions from IRAs Pub. 721, U.S. Civil Service Retirement Benefits
and if box 4 shows an amount (other than zero), attach Copy B to your return. Generally, if you receive Pub. 939, General Rule for Pensions and Annuities Pub. 969, HSAs and Other Tax−Favored Health Plans
payments that aren’t eligible rollover distributions, you can change your withholding or elect not to have Page 2 of 2
income tax withheld by giving the payer Form W−4P.

062128 0062128 00062128 0002 66660−0090 70439 01/16/23 −P

 CORRECTED (if checked)
PAYER’S name, street address, city or town, state or 1 Gross distribution OMB No. 1545−0119
province, country, ZIP or foreign postal code, and telephone no. Distributions From Pensions,
$6,365.22
STATE STREET RETIREE SERVICES FOR
BOEING FINANCIAL BENEFITS SERVICE CENTER 2a Taxable amount 2022 Annuities, Retirement or
Profit−Sharing Plans, IRAs,
P.O. BOX 28021 $6,365.22 Form 1099−R Insurance Contracts, etc.
ALBUQUERQUE, NM 87125−8021
1−866−422−3539 2b Taxable amount not Total distribution Copy B
determined Report this income
3 Capital gain (included in box 2a) 4 Federal income tax withheld on your federal tax
$8.78 return. If this form
PAYER’S TIN RECIPIENT’S TIN
shows federal income
04−3581074 511−62−3407 5 Employee contributions/Designated 6 Net unrealized appreciation in employer’s
tax withheld in
Roth contributions or insurance securities
RECIPIENT’S name, street address (including apt. no.), city or town, state or province, premiums box 4, attach this
country, and ZIP or foreign postal code copy to your return.
BILLY L DUNSWORTH 7 Distribution code(s) IRA / SEP / 8 Other
9125 E G ST 2 SIMPLE % This information
TACOMA, WA 98445−2153 9a Your percentage of total distribution 9b Total employee contributions is being furnished to the
% IRS.
14 State tax withheld 15 State/Payer’s state no. 16 State distribution

WA
10 Amount allocable to IRR within 11 1st year of desig. 12 FATCA filing 17 Local tax withheld 18 Name of locality 19 Local distribution
5 years Roth contrib. requirement

Account number (see instructions) 13 Date of payment

BNG QUAL
Form 1099−R www.irs.gov/Form1099R Department of the Treasury−Internal Revenue Service

CORRECTED (if checked)

PAYER’S name, street address, city or town, state or 1 Gross distribution OMB No. 1545−0119
province, country, ZIP or foreign postal code, and telephone no. $6,365.22 Distributions From Pensions,
STATE STREET RETIREE SERVICES FOR
BOEING FINANCIAL BENEFITS SERVICE CENTER 2a Taxable amount 2022 Annuities, Retirement or
Profit−Sharing Plans, IRAs,
P.O. BOX 28021 $6,365.22 Form 1099−R Insurance Contracts, etc.
ALBUQUERQUE, NM 87125−8021
1−866−422−3539 2b Taxable amount not Total distribution Copy C
determined For Recipient’s
3 Capital gain (included in box 2a) 4 Federal income tax withheld Records

PAYER’S TIN RECIPIENT’S TIN $8.78

04−3581074 511−62−3407 5 Employee contributions/Designated 6 Net unrealized appreciation in employer’s
Roth contributions or insurance securities
RECIPIENT’S name, street address (including apt. no.), city or town, state or province, premiums
country, and ZIP or foreign postal code
BILLY L DUNSWORTH 7 Distribution code(s) IRA / SEP / 8 Other This information is
9125 E G ST 2 SIMPLE % being furnished to
TACOMA, WA 98445−2153 9a Your percentage of total distribution 9b Total employee contributions the IRS.
%
14 State tax withheld 15 State/Payer’s state no. 16 State distribution

WA
10 Amount allocable to IRR within 11 1st year of desig. 12 FATCA filing 17 Local tax withheld 18 Name of locality 19 Local distribution
5 years Roth contrib. requirement
Account number (see instructions) 13 Date of payment
BNG QUAL
Form 1099−R (keep for your records) www.irs.gov/Form1099R Department of the Treasury−Internal Revenue Service

CORRECTED (if checked)

PAYER’S name, street address, city or town, state or 1 Gross distribution OMB No. 1545−0119
province, country, ZIP or foreign postal code, and telephone no. Distributions From Pensions,
$6,365.22
STATE STREET RETIREE SERVICES FOR
BOEING FINANCIAL BENEFITS SERVICE CENTER 2a Taxable amount 2022 Annuities, Retirement or
Profit−Sharing Plans, IRAs,
P.O. BOX 28021 $6,365.22 Form 1099−R Insurance Contracts, etc.
ALBUQUERQUE, NM 87125−8021
1−866−422−3539 2b Taxable amount not Total distribution Copy 2
determined File this copy
3 Capital gain (included in box 2a) 4 Federal income tax withheld with your state,
city, or local
PAYER’S TIN RECIPIENT’S TIN $8.78
income tax
04−3581074 511−62−3407 5 Employee contributions/Designated 6 Net unrealized appreciation in employer’s
return, when
Roth contributions or insurance securities
RECIPIENT’S name, street address (including apt. no.), city or town, state or province, premiums required.
country, and ZIP or foreign postal code
BILLY L DUNSWORTH 7 Distribution code(s) IRA / SEP / 8 Other
9125 E G ST 2 SIMPLE %
TACOMA, WA 98445−2153 9a Your percentage of total distribution 9b Total employee contributions
%
14 State tax withheld 15 State/Payer’s state no. 16 State distribution

WA
10 Amount allocable to IRR within 11 1st year of desig. 12 FATCA filing 17 Local tax withheld 18 Name of locality 19 Local distribution
5 years Roth contrib. requirement
Account number (see instructions) 13 Date of payment
BNG QUAL
Form 1099−R www.irs.gov/Form1099R Department of the Treasury−Internal Revenue Service
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