1099-R_1099-INT Inquiry Form (code GA5)

1099-R/1099-INT INQUIRY FORM
(NOTE: Please print in black or blue ink, and initial any changes that you make on this form.)
PART A: All information must be provided.
First Name
MI Last Name Permanent Home Address
City State Zip Code
Social Security Number (last 4 digits only)
XXX XX
Beneficiary Social Security Number (if applicable)
XXX XX
Apt. No. TRS Membership/Retirement Number
Primary Phone Number (Check one:
(
)
Alternate Phone Number (Check one:
(
)
Home
Home
Work
Mobile)
Work
Mobile)
Please keep your personal information with TRS up to date. We will update our records based on the information you provide above,
so do not enter a temporary address; instead, TRS suggests that you consult the U.S. Postal Service about having your mail forwarded
on a temporary basis. To register any changes to your permanent address (and/or phone number), please access our website or file a
“Member’s Change of Address Form” (code DM13), or if applicable, a “Beneficiary’s Change of Address Form” (code DM14) with TRS.
If you are providing new information above, please indicate the effective date (M/D/Y):
•T
his form should be filed with TRS at the address above if you have questions about the distribution(s) reported on a
1099-R or 1099-INT form(s) that you received from TRS, or if you would like to request a duplicate copy of your 1099
form(s). TRS anticipates that your inquiry/request will be addressed within 15 business days of our receipt of this
completed form.
•M
embers with active TRS accounts who received a lump-sum distribution from TRS in the past three years may view the
associated 1099 form(s) online by accessing our website; these members may also request a duplicate 1099 form online.
Please note that, if a member’s 1099 form(s) was corrected in a given year, neither the corrected forms nor the original
forms would be available for viewing online.
PART B: Please check the appropriate boxes below and specify the year of distribution in the space indicated.
I request a duplicate copy of my
1099-R form(s)
for tax year __________.
1099-INT form(s)
I have an inquiry about the 1099 form that I received in conjunction with the following distribution(s):
QPP retirement allowance
TDA annuity
Interest
axable excess withdrawal / Defaulted or taxable loan /
T
Refund of erroneous contributions
Withdrawal of funds upon resignation or termination
DA withdrawal / Required Minimum Distribution
T
(RMD) of TDA funds
GA5 (4/10)
Death benefit (If you check this box, please provide your Social Security number above.)
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PART C: If applicable, please describe your inquiry below.
PART D: Please sign and date this form.
MEMBER’S/BENEFICIARY’S SIGNATURE __________________________________ DATE (M/D/Y) __________________
GA5 (4/10)
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