KANSAS PUBLIC EMPLOYEES RETIREMENT SYSTEM

611 S KANSAS AVE SUITE 100

TOPEKA KS 66603 - 3869

RODNEY L HARTMAN
PO BOX 52
SHELL KNOBB MO 65747
 VOID CORRECTED (if checked)
PAYER'S name, street address, city or town, state or province, Distributions From

2020
1 Gross distribution
ZIP code or foreign postal code, and phone no. Pensions,
$ 23,019.60 Annuities,
KANSAS PUBLIC EMPLOYEES RETIREMENT SYSTEM Retirement or
2a Taxable amount Profit-Sharing Plans,
611 S KANSAS AVE SUITE 100 IRAs, Insurance
22,971.60 Form 1099-R
TOPEKA KS 66603 - 3869 $
1-888-275-5737, kpers@kpers.org 2b Taxable amount not Total Copy 2 File this
determined distribution copy with your
4 Federal income tax state, city, or
PAYER’S TIN RECIPIENT’S TIN 3 Capital gain (included in
box 2a) withheld local income tax
48-0944170 ***-**-6693
return, when
$ $ 1,454.00
required
Recipient's name, street address, city or town, state or province, country, 5 Employee contributions/ 6 Net unrealized
and zip or foreign postal code Designated Roth appreciation
contributions or in employer’s securities
insurance premiums
RODNEY L HARTMAN
$ 48.00 $
PO BOX 52
7 Distribution IRA/ 8 Other
SHELL KNOBB MO 65747 SEP/
code(s)
SIMPLE
7 $ %
9a Your percentage of total 9b Total employee
distribution contributions
% $
RETIRED 09-07
IRS NET INVESTMENT 1,457.42
Account number (see instructions)
EXCLUDED TO 12/31/20 640.00
213422-1425534
Form 1099-R

Instructions for Recipient

Box 2a. This part of the distribution is generally taxable. If there is no entry in
Generally, distributions from retirement plans (IRAs, qualified plans,
this box, the payer may not have all the facts needed to figure the taxable amount.
section 403(b) plans, and governmental section 457(b) plans), insurance
In that case, the first box in box 2b should be checked. You may want to get one
contracts, etc., are reported to recipients on Form 1099-R.
of the free publications from the IRS to help you figure the taxable amount. See
Additional information on the back of Copy 2. For an IRA distribution, see IRAs
Qualified plans. If your annuity starting date is after 1997, you must use
and Roth IRAs on this page. For a direct rollover, other than from a qualified plan
the simplified method to figure your taxable amount if your payer did not
to a Roth IRA, zero should be shown, and you must enter zero (-0-) on the
show the taxable amount in box 2a. See the instructions for Form 1040 or
“Taxable amount” line of your tax return.
1040NR.
If this is a total distribution from a qualified plan and you were born before
Recipient’s taxpayer identification number(TIN). For your protection, January 2, 1936 (or you are the beneficiary of someone born before January 2,
this form may show only the last four digits of your TIN (SSN, ITIN, 1936), you may be eligible for the 10-year tax option. See the Form 4972
ATIN,or EIN). However, the payer has reported your complete instructions for more information.
identification number to the IRS, and, where applicable, to state and/or local
governments. If you are an eligible retired public safety officer who elected to exclude from
income distributions from your eligible plan used to pay certain insurance
Account number. May show an account or other unique number the payer premiums, the amount shown in box 2a has not been reduced by the exclusion
assigned to distinguish your account. amount. See the instructions for Form 1040 or Form 1040A for more information.

Box 1. Shows the total amount you received this year. The amount may Box 2b. If the first box is checked, the payer was unable to determine the taxable
have been a direct rollover, a transfer or conversion to a Roth IRA, a amount, and box 2a should be blank except for an IRA. If the second box is
recharacterized IRA contribution; or you may have received it as periodic checked, the distribution was a total distribution that closed out your account.
payments, as nonperiodic payments, or as a total distribution. Report the
Box 3. If you received a lump-sum distribution from a qualified plan and were
amount on Form 1040 or 1040NR on the line for “IRAs”, “Pensions, and
born before January 2, 1936 (or you are the beneficiary of someone born before
annuities” (or the line for “Taxable amount”), and on Form 8606, as
January 2, 1936), you may be able to elect to treat this amount as a capital gain
applicable. However, if this is a lump-sum distribution, see Form 4972. If
on Form 4972 (not on Schedule D (Form 1040)). See the Form 4972 instructions.
you have not reached minimum retirement age, report your disability
For a charitable gift annuity, report as a long-term capital gain as explained in the
payments on the line for “Wages, salaries, tips, etc.” on your tax return.
instructions for Form 8949.
Also report on that line permissible withdrawals from eligible automatic
contribution arrangements and corrective distributions of excess deferrals,
excess contributions, or excess aggregate contributions except if you are
self-employed.
 VOID CORRECTED (if checked)

PAYER'S name, street address, city or town, state or province, 1 Gross distribution Distributions From
ZIP code or foreign postal code, and phone no.
$ 23,019.60 2020 Pensions,
Annuities,
Retirement or
2a Taxable amount
KANSAS PUBLIC EMPLOYEES RETIREMENT SYSTEM Profit-Sharing Plans,
Form 1099-R
611 S KANSAS AVE SUITE 100 22,971.60 IRAs, Insurance
$
TOPEKA KS 66603 - 3869 2b Taxable amount not Total Copy B
1-888-275-5737, kpers@kpers.org determined distribution Report this
income on your
PAYER’S TIN 3 Capital gain (included in 4 Federal income tax federal tax return.
RECIPIENT’S TIN
box 2a) withheld
48-0944170 ***-**-6693 If this form shows
$ $ 1,454.00
federal income
Recipient's name, street address, city or town, state or province, country, 5 Employee contributions/ 6 Net unrealized tax withheld in
and zip or foreign postal code Designated Roth appreciation box 4, attach this
contributions or in employer’s securities
copy to your
insurance premiums
RODNEY L HARTMAN return.
$ 48.00 $
PO BOX 52 IRA/
7 Distribution 8 Other
SHELL KNOBB MO 65747 SEP/
code(s) SIMPLE

7 $ %
9a Your percentage of total 9b Total employee
distribution contributions
% $
RETIRED 09-07
IRS NET INVESTMENT 1,457.42
Account number (see instructions) EXCLUDED TO 12/31/20 640.00
213422-1425534
Form 1099-R
Instructions for Recipient (continued)
Box 4. Shows federal income tax withheld. Include this amount on your Box 8. Not applicable to KPERS payments.
income tax return as tax withheld, and if box 4 shows an amount (other
than zero), attach Copy B to your return. Generally, if you will receive Box 9a. Not applicable to KPERS payments.
payments next year that are not eligible rollover distributions, you can
change your withholding or elect not to have income tax withheld by Box 9b. For a life annuity from a qualified plan or from a section 403(b) plan
giving the payer Form W-4P. (with after-tax contributions), an amount may be shown for the employee’s
total investment in the contract. It is used to compute the taxable part of the
Box 5. Generally, this shows the employee’s investment in the contract distribution. See Pub. 575.
(after-tax contributions), if any, recovered tax free this year.
Future Developments. For the latest information about developments related to
Box 6. Not applicable to KPERS payments. Form 1099-R and its instructions, such as legislation enacted after they were
published, go to www.irs.gov/form1099r.
Box 7. The following codes identify the distribution you received. For more
information on these distributions, see the instructions for your tax return.
Also, certain distributions may be subject to an additional 10% tax. See the
instructions for Forms 5329.
1-Early distribution, no known exception (in most cases, under age 59 ½).
2-Early distribution, exception applies (under age 59 ½). Additional information. You may want to see:
3-Disability.
4-Death. Form W-4P, Withholding Certificate for Pension or Annuity Payments,
7-Normal distribution. Form 4972, Tax on Lump-Sum Distributions,
A- May be eligible for 10-year tax option (see Form 4972). Pub. 575, Pension and Annuity Income,
G-Direct rollover of a distribution (other than a designated Roth account Pub. 939, General Rule for Pensions and Annuities.
distribution) to a qualified plan, a section 403(b) plan, a governmental
section 457(b) plan, or an IRA.
 VOID CORRECTED (if checked)

PAYER'S name, street address, city or town, state or province, 1 Gross distribution Distributions From
ZIP code or foreign postal code, and phone no.
$ 23,019.60 2020 Pensions,
Annuities,
Retirement or
KANSAS PUBLIC EMPLOYEES RETIREMENT SYSTEM 2a Taxable amount
Profit-Sharing Plans,
611 S KANSAS AVE SUITE 100 22,971.60 Form 1099-R IRAs, Insurance
$
TOPEKA KS 66603 - 3869
1-888-275-5737, kpers@kpers.org 2b Taxable amount not Total Copy 2 File this
determined distribution
copy with your
PAYER’S TIN RECIPIENT’S TIN 3 Capital gain (included in 4 Federal income tax state, city, or
box 2a) withheld local income tax
48-0944170 ***-**-6693
$ $ 1,454.00 return, when
required
Recipient's name, street address, city or town, state or province, country, 5 Employee contributions/ 6 Net unrealized
and zip or foreign postal code Designated Roth appreciation
contributions or in employer’s securities
insurance premiums
RODNEY L HARTMAN 48.00
$ $
PO BOX 52 7 Distribution IRA/ 8 Other
SHELL KNOBB MO 65747 code(s) SEP/
SIMPLE
7 $ %
9a Your percentage of total 9b Total employee
distribution % $ contributions
RETIRED 09-07
IRS NET INVESTMENT 1,457.42
Account number (see instructions) EXCLUDED TO 12/31/20 640.00
213422-1425534
Form 1099-R