Form 5498-Esa - Coverdell Esa Contribution Information - 2016 Page 2

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CORRECTED
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 B
TRUSTEE’S/ISSUER’S federal identification no. BENEFICIARY'S social security number
For Beneficiary
BENEFICIARY'S name
This information
is being furnished
to the Internal
Street address (including apt. no.)
Revenue Service.
City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)
5498-ESA
(keep for your records)
Form
Department of the Treasury - Internal Revenue Service

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