Name of recipient of distribution Identifying number Part I. Complete this part to see if you can use Form 4972 1 Was this a distribution of a plan participant’s entire balance (excluding deductible voluntary employee contributions and certain forfeited amounts) from all of an employer’s qualified plans of one kind (for example, pension, profit-sharing, or stock bonus)? If “No,” don't use this form Yes No 1 2 Did you roll over any part of the distribution? If “Yes,” don't use this form 2 3 Was this distribution paid to you as a beneficiary of a plan participant who was born before January 2, 1936? 3 4 Were you (a) a plan participant who received this distribution, (b) born before January 2, 1936, and (c) a participant in the plan for at least 5 years before the year of the distribution? If you answered “No” to both questions 3 and 4, don't use this form. 4 5a Did you use Form 4972 after 1986 for a previous distribution from your own plan? If “Yes,” don't use this form for a 2016 distribution from your own plan 5a b If you are receiving this distribution as a beneficiary of a plan participant who died, did you use Form 4972 for a previous distribution received as a beneficiary of that participant after 1986? If “Yes,” don't use this form for this distribution 5b Part II. Complete this part to choose the 20% capital gain election (see instructions) 6 Capital gain part from Form 1099-R, box 3 6 7 Multiply line 6 by 20% (0.2) 7 If you also choose to use Part III, go to line 8. Otherwise, include the amount from line 7 in the total on Form 1040, line 44; Form 1040NR, line 42; or Form 1041, Schedule G, line 1b. Part III. Complete this part to choose the 10-year tax option (see instructions) 8 If you completed Part II, enter the amount from Form 1099-R, box 2a minus box 3. If you didn't complete Part II, enter the amount from box 2a. Multiple recipients (and recipients who elect to include net unrealized appreciation (NUA) in taxable income) see instructions 8 9 Death benefit exclusion for a beneficiary of a plan participant who died before August 21, 1996 9 10 Total taxable amount. Subtract line 9 from line 8 10 11 Current actuarial value of annuity from Form 1099-R, box 8. If none, enter -0- 11 12 Adjusted total taxable amount. Add lines 10 and 11. If this amount is $70000 or more, skip lines 13 through 16, enter this amount on line 17, and go to line 18 12 13 Multiply line 12 by 50% (0.50), but don't enter more than $10,000 13 14 Subtract $20,000 from line 12. If line 12 is $20,000 or less, enter -0- 14 15 Multiply line 14 by 20% (0.20) 15 16 Minimum distribution allowance. Subtract line 15 from line 13 16 17 Subtract line 16 from line 12 17 18 Federal estate tax attributable to lump-sum distribution 18 19 Subtract line 18 from line 17. If line 11 is zero, skip lines 20 through 22 and go to line 23 19 20 Divide line 11 by line 12 and enter the result as a decimal (rounded to at least three places) 20 21 Multiply line 16 by the decimal on line 20 21 22 Subtract line 21 from line 11 22 23 Multiply line 19 by 10% (0.10) 23 24 Tax on amount on line 23. Use the Tax Rate Schedule in the instructions 24 25 Multiply line 24 by 10.0. If line 11 is zero, skip lines 26 through 28, enter this amount on line 29, and go to line 30 25 26 Multiply line 22 by 10% (0.10) 26 27 Tax on amount on line 26. Use the Tax Rate Schedule in the instructions 27 28 Multiply line 27 by 10.0 28 29 Subtract line 28 from line 25. Multiple recipients see instructions 29 30 Tax on lump-sum distribution. Add lines 7 and 29. Also include this amount in the total on Form 1040, line 44; Form 1040NR, line 42; or Form 1041, Schedule G, line 1b 30