Form 5498 - Ira Contribution Information - 2012
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1
2
3
4
52828
VOID
CORRECTED
TRUSTEE’S or ISSUER'S name, street address, city, state, and ZIP code
1 IRA contributions (other
OMB No. 1545-0747
than amounts in boxes
IRA
2-4, 8-10, 13a, and 14a)
2012
Contribution
$
Information
2 Rollover contributions
5498
$
Form
3 Roth IRA conversion
4 Recharacterized
Copy A
amount
contributions
$
$
For
Internal Revenue
TRUSTEE’S or ISSUER’S federal
PARTICIPANT’S social security
5 Fair market value of account
6 Life insurance cost included in
Service Center
identification no.
number
box 1
$
$
File with Form 1096.
PARTICIPANT’S name
7 IRA
SEP
SIMPLE
Roth IRA
8 SEP contributions
9 SIMPLE contributions
For Privacy Act
$
$
and Paperwork
Street address (including apt. no.)
10 Roth IRA contributions
11 Check if RMD for 2013
Reduction Act
$
Notice, see the
12a RMD date
12b RMD amount
2012 General
$
Instructions for
City, state, and ZIP code
13a Postponed contribution
13b Year
13c Code
Certain
$
Information
14a Repayments
14b Code
Returns.
$
Account number (see instructions)
5498
Form
Cat. No. 50010C
Department of the Treasury - Internal Revenue Service
Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page
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