CORRECTED (if checked) Distributions From

PAYER'S TIN RECIPIENT'S TIN 1 Gross distribution OMB No. 1545-0119 Pensions, Annuities,
04-6568107 xxx-xx-1960 $15,297.20 Retirement or
2023 Profit-Sharing Plans,
PAYER'S name, street address, city, state, and ZIP code 2a Taxable amount IRAs, Insurance
FIDELITY INVESTMENTS $15,297.20 Form 1099-R Contracts, etc.
INSTITUTIONAL OPERATIONS CO.
100 MAGELLAN WAY KW1C 2b Taxable amount Total Copy B
COVINGTON, KY 41015-1987 not determined distribution Report this income
12455 1-800-425-2363 3 Capital gain (included in box 2a) 4 Federal income tax withheld on your federal tax
AMERICAN AIRLINES INC 401K PLAN $0.00 $1,529.74 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 4,
eDelivery contrib or insurance premiums in employer's securities attach this copy
$0.00 $0.00 to your return.
DIONNE BOULER 7 Distribution code(s) IRA/SEP/ 8 Other % This information is being
10946 S AVENUE G SIMPLE furnished to the Internal
CHICAGO, IL 60617-6744 1 $0.00 Revenue Service.
9a Your percentage of 9b Total employee contributions 10 Amount allocable to IRR
total distribution within 5 years
% $ $0.00
14 State tax withheld 15 State/Payer's state no. 16 State distribution

Account number (see instructions) 11 1st year of desig.Roth 12 FATCA filing $0.00 IL $
20240106014403458735 contrib. requirement 13 Date of payment
Form 1099-R Department of the 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-1960 $15,297.20 Retirement or
2023 Profit-Sharing Plans,
PAYER'S name, street address, city, state, and ZIP code 2a Taxable amount IRAs, Insurance
FIDELITY INVESTMENTS $15,297.20 Form 1099-R Contracts, etc.
INSTITUTIONAL OPERATIONS CO.
100 MAGELLAN WAY KW1C 2b Taxable amount Total Copy C
COVINGTON, KY 41015-1987 not determined distribution For Recipient's
12455 1-800-425-2363 3 Capital gain (included in box 2a) 4 Federal income tax withheld Records
AMERICAN AIRLINES INC 401K PLAN $0.00 $1,529.74

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
DIONNE BOULER 7 Distribution code(s) IRA/SEP/ 8 Other % This information is being
10946 S AVENUE G SIMPLE furnished to the Internal
CHICAGO, IL 60617-6744 1 $0.00 Revenue Service.
9a Your percentage of 9b Total employee contributions 10 Amount allocable to IRR
total distribution within 5 years
% $ $0.00
14 State tax withheld 15 State/Payer's state no. 16 State distribution

Account number (see instructions) 11 1st year of desig.Roth 12 FATCA filing $0.00 IL $
20240106014403458735 contrib. requirement 13 Date of payment
Form 1099-R (keep for your records) Department of the 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-1960 $15,297.20 Retirement or
2023 Profit-Sharing Plans,
PAYER'S name, street address, city, state, and ZIP code 2a Taxable amount IRAs, Insurance
FIDELITY INVESTMENTS $15,297.20 Form 1099-R Contracts, etc.
INSTITUTIONAL OPERATIONS CO.
100 MAGELLAN WAY KW1C 2b Taxable amount Total Copy 2
COVINGTON, KY 41015-1987 not determined distribution File this copy
12455 1-800-425-2363 3 Capital gain (included in box 2a) 4 Federal income tax withheld with your state,
AMERICAN AIRLINES INC 401K PLAN $0.00 $1,529.74 city, or local
income tax
RECIPIENT'S name, street address (including apt. no.), city, state, and ZIP code 5 Employee contrib/desig Roth 6 Net unrealized appreciation return, when
contrib or insurance premiums in employer's securities required
$0.00 $0.00
DIONNE BOULER 7 Distribution code(s) IRA/SEP/ 8 Other %
10946 S AVENUE G SIMPLE
CHICAGO, IL 60617-6744 1 $0.00
9a Your percentage of 9b Total employee contributions 10 Amount allocable to IRR
total distribution within 5 years
% $ $0.00
14 State tax withheld 15 State/Payer's state no. 16 State distribution

Account number (see instructions) 11 1st year of desig.Roth 12 FATCA filing $0.00 IL $
20240106014403458735 contrib. requirement 13 Date of payment
Form 1099-R Department of the Treasury - Internal Revenue Service