CORRECTED (if checked) Distributions From

PAYER'S TIN RECIPIENT'S TIN 1 Gross distribution OMB No. 1545-0119 Pensions, Annuities,
04-6568107 xxx-xx-4245 $1,291.62 Retirement or
2021 Profit-Sharing Plans,
PAYER'S name, street address, city, state, and ZIP code 2a Taxable amount IRAs, Insurance
FIDELITY INVESTMENTS $1,291.62 Form 1099-R Contracts, etc.
INSTITUTIONAL OPERATIONS CO.
100 MAGELLAN WAY KW1C 2b Taxable amount Total X Copy B
COVINGTON, KY 41015-1987 not determined distribution Report this income
28668 1-800-425-2363 3 Capital gain (included in box 2a) 4 Federal income tax withheld on your federal tax
POLARIS BOATS 401K PLAN $0.00 $0.00 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,
PRTAX2E2022011209.02.081637749 contrib or insurance premiums in employer's securities attach this copy
$0.00 $0.00 to your return.
DENVER W HEDRICK 7 Distribution code(s) IRA/SEP/ 8 Other % This information is being
301 BROADMORE ESTATES SIMPLE furnished to the Internal
GOSHEN, IN 46528 1M $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 IN 0005140129001 $
20220108021302574559 contrib. requirement 13 Date of payment
Form 1099-R Department of the Treasury - Internal Revenue Service

*28668 00000000021R*
CORRECTED (if checked) Distributions From
PAYER'S TIN RECIPIENT'S TIN 1 Gross distribution OMB No. 1545-0119 Pensions, Annuities,
04-6568107 xxx-xx-4245 $1,291.62 Retirement or
2021 Profit-Sharing Plans,
PAYER'S name, street address, city, state, and ZIP code 2a Taxable amount IRAs, Insurance
FIDELITY INVESTMENTS $1,291.62 Form 1099-R Contracts, etc.
INSTITUTIONAL OPERATIONS CO.
100 MAGELLAN WAY KW1C 2b Taxable amount Total X Copy C
COVINGTON, KY 41015-1987 not determined distribution For Recipient's
28668 1-800-425-2363 3 Capital gain (included in box 2a) 4 Federal income tax withheld Records
POLARIS BOATS 401K PLAN $0.00 $0.00

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
DENVER W HEDRICK 7 Distribution code(s) IRA/SEP/ 8 Other % This information is being
301 BROADMORE ESTATES SIMPLE furnished to the Internal
GOSHEN, IN 46528 1M $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 IN 0005140129001 $
20220108021302574559 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-4245 $1,291.62 Retirement or
2021 Profit-Sharing Plans,
PAYER'S name, street address, city, state, and ZIP code 2a Taxable amount IRAs, Insurance
FIDELITY INVESTMENTS $1,291.62 Form 1099-R Contracts, etc.
INSTITUTIONAL OPERATIONS CO.
100 MAGELLAN WAY KW1C 2b Taxable amount Total X Copy 2
COVINGTON, KY 41015-1987 not determined distribution File this copy
28668 1-800-425-2363 3 Capital gain (included in box 2a) 4 Federal income tax withheld with your state,
POLARIS BOATS 401K PLAN $0.00 $0.00 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
DENVER W HEDRICK 7 Distribution code(s) IRA/SEP/ 8 Other %
301 BROADMORE ESTATES SIMPLE
GOSHEN, IN 46528 1M $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 IN 0005140129001 $
20220108021302574559 contrib. requirement 13 Date of payment
Form 1099-R Department of the Treasury - Internal Revenue Service