Form 5498-Esa - Coverdell Esa Contribution Information - 2013 Page 5
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6VOID
CORRECTED
TRUSTEE’S or ISSUER'S name, street address, city or town, province or
1 Coverdell ESA contributions
OMB No. 1545-1815
Coverdell ESA
state, country, and ZIP or foreign postal code
2013
Contribution
$
Information
2 Rollover contributions
5498-ESA
$
Form
Copy C
TRUSTEE’S/ISSUER’S federal identification no. BENEFICIARY'S social security number
For Trustee
BENEFICIARY'S name
For Privacy Act
and Paperwork
Reduction Act
Street address (including apt. no.)
Notice, see the
2013 General
City or town, province or state, country, and ZIP or foreign postal code
Instructions for
Certain
Information
Account number (see instructions)
Returns.
5498-ESA
Form
Department of the Treasury - Internal Revenue Service
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