Form 5498-Esa - Coverdell Esa Contribution Information - 2012 Page 5

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VOID
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 C
TRUSTEE’S/ISSUER’S federal identification no. BENEFICIARY'S social security number
For Trustee
BENEFICIARY'S name
For Privacy Act
and Paperwork
Reduction Act
Street address (including apt. no.)
Notice, see the
2012 General
City, state, and ZIP code
Instructions for
Certain
Information
Account number (see instructions)
Returns.
5498-ESA
Form
Department of the Treasury - Internal Revenue Service

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