Form 5498-Esa - Coverdell Esa Contribution Information - 2016
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5VOID
CORRECTED
7272
TRUSTEE’S or ISSUER'S name, street address, city or town, state or
1 Coverdell ESA contributions
OMB No. 1545-1815
province, country, and ZIP or foreign postal code
Coverdell ESA
2016
$
Contribution
2 Rollover contributions
Information
5498-ESA
$
Form
Copy A
TRUSTEE’S/ISSUER’S federal identification no. BENEFICIARY'S social security number
For
Internal Revenue
BENEFICIARY'S name
Service Center
File with Form 1096.
Street address (including apt. no.)
For Privacy Act and
Paperwork Reduction
Act Notice, see the
City or town, state or province, country, and ZIP or foreign postal code
2016 General
Instructions for
Certain Information
Account number (see instructions)
Returns.
5498-ESA
Form
Cat. No. 34011J
Department of the Treasury - Internal Revenue Service
Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page
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