Form 1099R 2003 ActiveGuide Coach

Taxpayer PAYER's Name PAYER's Address , - State - AR AK AL AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MT MS NC NE NH NJ ND NV NM NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY 1. Gross Distribution $ 2a. Taxable Amount $ 2b. Taxable amount not determined Total Distribution PAYER's Federal ID# - RECIPIENT's Social Security# 3. Capital gain (included in box 2a) $ 4. Federal income tax withheld $ RECIPIENT's Name & Address 5. Employee contributions or insurance premiums $ 6. Net unrealized appreciation in employer's securities $ 7.Distribution Code - 1 2 3 4 5 6 7 8 9 A D E F G J N P Q R S T IRA/SEP/ SIMPLE 8. Other $ % 9a. Your percent of total distribution % 9b. Total Employee contributions $ Account Number (Optional) 10. State Tax Withheld $ AR AK AL AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MT MS NC NE NH NJ ND NV NM NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY 11. State/Payer's State# 12. State Distribution $ $ AR AK AL AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MT MS NC NE NH NJ ND NV NM NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY $   13. Local Tax Withheld $ 14. Name of Locality 15. Local Distribution $ $ $

---