Form 5498 - Ira Contribution Information - 2016 Page 3
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1
2
3
4
5
6CORRECTED (if checked)
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)
2016
Contribution
$
Information
2 Rollover contributions
$
5498
Form
3 Roth IRA conversion
4 Recharacterized
Copy B
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
Participant
$
$
PARTICIPANT’S name
7 IRA
This information
SEP
SIMPLE
Roth IRA
8 SEP contributions
9 SIMPLE contributions
is being
$
$
furnished to
the Internal
Street address (including apt. no.)
10 Roth IRA contributions
11 If checked, required minimum
distribution for 2017
Revenue
$
Service.
12a RMD date
12b RMD amount
$
City or town, state or province, country, and ZIP or foreign postal code
13a Postponed contribution
13b Year
13c Code
$
14a Repayments
14b Code
$
Account number (see instructions)
15a FMV of certain specified
15b Code(s)
assets
$
5498
(keep for your records)
Form
Department of the Treasury - Internal Revenue Service
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