Form 5498 - Ira Contribution Information - 2012 Page 2
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1
2
3
4
5CORRECTED (if checked)
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 B
amount
contributions
$
$
For
TRUSTEE’S or ISSUER’S federal
PARTICIPANT’S social security
5 Fair market value of account
6 Life insurance cost included in
identification no.
number
box 1
Participant
$
$
PARTICIPANT’S name
7 IRA
SEP
SIMPLE
Roth IRA
This information
8
9 SIMPLE contributions
SEP contributions
is being
$
$
furnished to
the Internal
Street address (including apt. no.)
10 Roth IRA contributions
11 If checked, required minimum
distribution for 2013
Revenue
$
Service.
12a RMD date
12b RMD amount
$
City, state, and ZIP code
13a Postponed contribution
13b Year
13c Code
$
14a Repayments
14b Code
$
Account number (see instructions)
5498
Form
(keep for your records)
Department of the Treasury - Internal Revenue Service
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