CORRECTED (if checked) Distributions From
PAYER'S TIN RECIPIENT'S TIN 1 Gross distribution OMB No. 1545-0119 Pensions, Annuities,
04-6568107 xxx-xx-6821 $12,600.00 Retirement or
2019 Profit-Sharing Plans,
PAYER'S name, street address, city, state, and ZIP code 2a Taxable amount IRAs, Insurance
FIDELITY INVESTMENTS Form 1099-R Contracts, etc.
INSTITUTIONAL OPERATIONS CO.
100 MAGELLAN WAY KW1C 2b Taxable amount X Total Copy B
COVINGTON, KY 41015-1987 not determined distribution Report this income
38176 3 Capital gain (included in box 2a) 4 Federal income tax withheld on your federal tax
EVANGELICAL LUTHERAN CHURCH $0.00 $0.00 return. If this form
shows federal income
RECIPIENT'S name, street address (including apt. no.), city, state, and ZIP code 5 Employee contrib/desig Roth 6 Net unrealized appreciation tax withheld in box
PRTAX2E2020012302.17.260010160 contrib or insurance premiums in employer's securities 4, attach this copy
$0.00 $0.00 to your return.
O DENNIS MIMS 7 Distribution code(s) IRA/SEP/ 8 Other % This information is being
75 BLACKWALNUT TRL SIMPLE furnished to the Internal
HAMPTON, GA 30228 7 $0.00 Revenue Service.
9a Your percentage of 9b Total employee contributions 10 Amount allocable to IRR
total distribution within 5 years
% $ $0.00
12 State tax withheld 13 State/Payer's state no. 14 State distribution
Account number (see instructions) 11 1st year of desig.Roth FATCA filing $0.00 GA 1847797JJ $
20200104023604517609 contrib. requirement Date of payment
Form 1099-R Department of the Treasury - Internal Revenue Service
*38176 00000000019R*
CORRECTED (if checked) Distributions From
PAYER'S TIN RECIPIENT'S TIN 1 Gross distribution OMB No. 1545-0119 Pensions, Annuities,
04-6568107 xxx-xx-6821 $12,600.00 Retirement or
2019 Profit-Sharing Plans,
PAYER'S name, street address, city, state, and ZIP code 2a Taxable amount IRAs, Insurance
FIDELITY INVESTMENTS Form 1099-R Contracts, etc.
INSTITUTIONAL OPERATIONS CO.
100 MAGELLAN WAY KW1C 2b Taxable amount X Total
COVINGTON, KY 41015-1987 not determined distribution Copy C
38176 3 Capital gain (included in box 2a) 4 Federal income tax withheld For Recipient's
EVANGELICAL LUTHERAN CHURCH $0.00 $0.00 Records
This information is being
RECIPIENT'S name, street address (including apt. no.), city, state, and ZIP code 5 Employee contrib/desig Roth 6 Net unrealized appreciation furnished to the Internal
contrib or insurance premiums in employer's securities Revenue Service.
$0.00 $0.00
O DENNIS MIMS 7 Distribution code(s) IRA/SEP/ 8 Other %
75 BLACKWALNUT TRL SIMPLE
HAMPTON, GA 30228 7 $0.00
9a Your percentage of 9b Total employee contributions 10 Amount allocable to IRR
total distribution % $ within 5 years
$0.00
12 State tax withheld 13 State/Payer's state no. 14 State distribution
Account number (see instructions) 11 1st year of desig.Roth FATCA filing $0.00 GA 1847797JJ $
20200104023604517609 contrib. requirement Date of payment
Form 1099-R (keep for your records) Department of Treasury - Internal Revenue Service
CORRECTED (if checked) Distributions From
PAYER'S TIN RECIPIENT'S TIN 1 Gross distribution OMB No. 1545-0119 Pensions, Annuities,
04-6568107 xxx-xx-6821 $12,600.00 Retirement or
2019 Profit-Sharing Plans,
PAYER'S name, street address, city, state, and ZIP code 2a Taxable amount IRAs, Insurance
FIDELITY INVESTMENTS Form 1099-R Contracts, etc.
INSTITUTIONAL OPERATIONS CO.
100 MAGELLAN WAY KW1C 2b Taxable amount X Total Copy 2
COVINGTON, KY 41015-1987 not determined distribution File this copy with
38176 3 Capital gain (included in box 2a) 4 Federal income tax withheld your state, city, or
EVANGELICAL LUTHERAN CHURCH $0.00 $0.00 local income tax
return, when required.
RECIPIENT'S name, street address (including apt. no.), city, state, and ZIP code 5 Employee contrib/desig Roth 6 Net unrealized appreciation
contrib or insurance premiums in employer's securities
$0.00 $0.00
O DENNIS MIMS 7 Distribution code(s) IRA/SEP/ 8 Other %
75 BLACKWALNUT TRL SIMPLE
HAMPTON, GA 30228 7 $0.00
9a Your percentage of 9b Total employee contributions 10 Amount allocable to IRR
total distribution % $ within 5 years
$0.00
12 State tax withheld 13 State/Payer's state no. 14 State distribution
Account number (see instructions) 11 1st year of desig.Roth FATCA filing $0.00 GA 1847797JJ $
20200104023604517609 contrib. requirement Date of payment
Form 1099-R Department of Treasury - Internal Revenue Service
