Form 5498-Qa - Able Account Contribution Information - 2016 Page 2

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CORRECTED
ISSUER'S name, street address, city or town, state or province, country, and
1 ABLE contributions
OMB No. 1545-2262
ZIP or foreign postal code
ABLE Account
2016
$
Contribution
2 Rollover contributions
Information
5498-QA
$
Form
Copy B
ISSUER’S federal identification no.
BENEFICIARY'S social security number
3 Cumulative contributions
4 Fair market value
$
$
For Beneficiary
BENEFICIARY'S name
5 If checked, account was
6 Basis of eligibility
opened in 2016
This information
is being furnished
to the Internal
Street address (including apt. no.)
7 Code
Revenue Service.
City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)
5498-QA
(keep for your records)
Form
Department of the Treasury - Internal Revenue Service

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