1099-R on Roth 401k excess deferral

[karl]

First time we have a Roth 401k excess deferral and not sure of how to prepare 1099R. Under age 50 participant deferred $17,500 in 2012 all as Roth 401k deferral. In 2013 before 4/15 processing refund of $500 and have calculated $51 in gains. Should there be two 2013 1099Rs? One for the Roth deferral and one for the gain.

1)Box 1: $500

Box 2a: $0

Box 4: $0

Box 7: PB

Box 11: 2009 is date of 1st year contrib

2)Box 1: $51

Box 2a: $51

Box 4: $0

Box 7: 8

Any thoughts or confirmation is appreciated.