Form 5498-Esa - Coverdell Esa Contribution Information - 2012 Page 3

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CORRECTED
TRUSTEE’S or ISSUER'S name, street address, city, state, and ZIP code
1 Coverdell ESA contributions
OMB No. 1545-1815
Coverdell ESA
2012
Contribution
$
Information
2 Rollover contributions
5498-ESA
$
Form
Copy B
TRUSTEE’S/ISSUER’S federal identification no. BENEFICIARY'S social security number
For Beneficiary
BENEFICIARY'S name
The information
in boxes 1 and 2
is being furnished
Street address (including apt. no.)
to the Internal
Revenue Service.
City, state, and ZIP code
Account number (see instructions)
5498-ESA
Form
(keep for your records)
Department of the Treasury - Internal Revenue Service

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