About the plan participant:
Date of birth (mm/dd/yyyy):
Tax year: Filing Status:
Estimated taxable income (EXCLUDING this distribution) for the current tax year: $

About the Distributable Amount:
Type of Plan:
Total distribution amount: $ Date of distribution (mm/dd/yyyy):
Total after-tax contributions: $
Cumulative prior PS-58 costs: $
Total prior loans treated as taxable income: $
Net unrealized appreciation on employer securities:
Basis: $ Market value: $
Check if 5 or 10 year averaging, or capital gains treatment or pre-1974 amounts has EVER been used.


Still River Retirement Planning Software, Inc.
· 75 Broad St., Pittsfield, MA 01201
· Contact us by email: info@stillriverretire.com