Form 5498 - Ira Contribution Information - 2014 Page 5
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6VOID
CORRECTED
TRUSTEE’S or ISSUER'S name, street address, city or town, state or
1 IRA contributions (other
OMB No. 1545-0747
province, country, and ZIP or foreign postal code
than amounts in boxes
IRA
2-4, 8-10, 13a, and 14a)
2014
Contribution
$
Information
2 Rollover contributions
$
5498
Form
3 Roth IRA conversion
4 Recharacterized
Copy C
amount
contributions
$
$
TRUSTEE’S or ISSUER’S federal
PARTICIPANT’S social security
identification no.
number
For
5 Fair market value of account
6 Life insurance cost included in
box 1
Trustee or Issuer
$
$
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 2015
Reduction Act
$
Notice, see the
12a RMD date
12b RMD amount
2014 General
$
City or town, state or province, country, and ZIP or foreign postal code
Instructions for
13a Postponed contribution
13b Year
13c Code
Certain
$
Information
Returns.
14a Repayments
14b Code
$
Account number (see instructions)
15a FMV of certain specified
15b Code(s)
assets
$
5498
Form
Department of the Treasury - Internal Revenue Service
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