VOID CORRECTED

IRA contributions (other

than amounts in boxes

2–4 and 8–10)

TRUSTEE’S or ISSUER’S name, street address, city, state, and ZIP code 1

IRA

Contribution

Information

$

2 Rollover contributions

$

TRUSTEE’S or ISSUER’S Federal identification no. PARTICIPANT’S social security number 3 Roth IRA conversion amount

$

PARTICIPANT’S name 5 Fair market value of account

$

Street address (including apt. no.)

City, state, and ZIP code

Account number (optional)

Form 5498 Department of the Treasury - Internal Revenue Service

2828

Cat. No. 50010C

Copy A

For

Internal Revenue

Service Center

File with Form 1096.

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2003 General

Instructions for

Forms 1099, 1098,

5498, and W-2G.

Form 5498

OMB No. 1545-0747

7 IRA SEP SIMPLE

8 SEP contributions 9 SIMPLE contributions

$ $

10 Roth IRA contributions

$

Roth IRA

Life insurance cost

included in box 1

6

$

Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page

4 Recharacterized contributions

$

2003

11 Check if RMD

for 2004
CORRECTED (if checked)

TRUSTEE’S or ISSUER’S name, street address, city, state, and ZIP code

TRUSTEE’S or ISSUER’S Federal identification no. PARTICIPANT’S social security number

PARTICIPANT’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (optional)

Form 5498 Department of the Treasury - Internal Revenue Service

For

Participant

Copy B

(keep for your records)

IRA

Contribution

Information

This information

is being

furnished to

the Internal

Revenue

Service.

IRA contributions (other

than amounts in boxes

2–4 and 8–10)

1

$

2 Rollover contributions

$

3 Roth IRA conversion amount

$

5 Fair market value of account

$

Form 5498

OMB No. 1545-0747

7 IRA SEP SIMPLE

8 SEP contributions 9 SIMPLE contributions

$ $

10 Roth IRA contributions

$

Roth IRA

Life insurance cost

included in box 1

6

$

4 Recharacterized contributions

$

2003

11 If checked required

minimum distribution 

for 2004
CORRECTED (if checked)

TRUSTEE’S or ISSUER’S name, street address, city, state, and ZIP code

TRUSTEE’S or ISSUER’S Federal identification no. PARTICIPANT’S social security number

PARTICIPANT’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (optional)

Form 5498 Department of the Treasury - Internal Revenue Service

For

Participant

Copy B

(keep for your records)

IRA

Contribution

Information

This information

is being

furnished to

the Internal

Revenue

Service.

IRA contributions (other

than amounts in boxes

2–4 and 8–10)

1

$

2 Rollover contributions

$

3 Roth IRA conversion amount

$

5 Fair market value of account

$

Form 5498

OMB No. 1545-0747

7 IRA SEP SIMPLE

8 SEP contributions 9 SIMPLE contributions

$ $

10 Roth IRA contributions

$

Roth IRA

Life insurance cost

included in box 1

6

$

4 Recharacterized contributions

$

2003

11 If checked required

minimum distribution 

for 2004
The information on Form 5498 is submitted to the Internal Revenue

Service by the trustee or issuer of your individual retirement arrangement

(IRA) to report contributions, including any catch-up contributions, and

the fair market value of the account. For information about IRAs, see

Pub. 590, Individual Retirement Arrangements (IRAs), and Pub. 560,

Retirement Plans for Small Business (SEP, SIMPLE, and Qualified Plans).

Box 6. For endowment contracts only, shows the amount allocable to the

cost of life insurance. Subtract this amount from your allowable IRA

contribution included in box 1 to compute your IRA deduction.

Box 5. Shows the fair market value of your account at year end.

However, if a decedent’s name is shown, the amount reported may be

Box 1. Shows traditional IRA contributions for 2003 you made in 2003

and through April 15, 2004. These contributions may be deductible on

your Form 1040 or 1040A. However, if you or your spouse was an active

participant in an employer’s pension plan, these contributions may not be

deductible. This box does not include amounts in boxes 2–4 and 8–10.

Box 2. Shows any rollover, including a direct rollover to a traditional IRA,

you made in 2003. It does not show any amounts you converted from

your traditional IRA, SEP IRA, or SIMPLE IRA to a Roth IRA. They are

shown in box 3. See the Form 1040 or 1040A instructions for information

on how to report rollovers. If you have ever made any nondeductible

contributions to your traditional IRA or SEP IRA and you did not roll over

the total distribution, use Form 8606, Nondeductible IRAs, to figure the

taxable amount. If property was rolled over, see Pub. 590.

Box 7. May show the kind of IRA reported on this Form 5498.

Box 8. Shows SEP contributions made in 2003, including contributions

made in 2003 for 2002, but not including contributions made in 2004 for

2003. If made by your employer, do not deduct on your income tax

return. If you made the contributions as a self-employed person (or

partner), they may be deductible. See Pub. 560.

Box 9. Shows SIMPLE contributions made in 2003. If made by your

employer, do not deduct on your income tax return. If you made the

contributions as a self-employed person (or partner), they may be

deductible. See Pub. 560.

Box 10. Shows Roth IRA contributions you made in 2003 and through

April 15, 2004. Do not deduct on your income tax return.

Box 3. Shows the amount converted from a traditional IRA, SEP IRA, or SIMPLE

IRA to a Roth IRA in 2003. Use Form 8606 to figure the taxable amount.

Instructions to Participant

Box 4. Shows amounts recharacterized from transferring any part of the

contribution (plus earnings) from one type of IRA to another. See Pub. 590.

Box 11. If the box is checked, you must take a required minimum

distribution (RMD) for 2004. An RMD may be required even if the box is

not checked. The amount, or offer to compute the amount, and date of

the RMD will be furnished to you by January 31 either on Form 5498 (in

the blank box to the left of box 10) or in a separate statement. If you

don’t take the RMD in 2004, you are subject to a 50% excise tax on the

amount not distributed. See Pub. 590 for details.

the FMV on the date of death. If the FMV shown is zero for a decedent,

the executor or administrator of the estate may request a date-of-death

value from the financial institution.
VOID CORRECTED

TRUSTEE’S or ISSUER’S name, street address, city, state, and ZIP code

TRUSTEE’S or ISSUER’S Federal identification no. PARTICIPANT’S social security number

PARTICIPANT’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (optional)

Form 5498 Department of the Treasury - Internal Revenue Service

For

Trustee or Issuer

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2003 General

Instructions for

Forms 1099,

1098, 5498,

and W-2G.

Copy C

IRA

Contribution

Information

IRA contributions (other

than amounts in boxes

2–4 and 8–10)

1

$

2 Rollover contributions

$

3 Roth IRA conversion amount

$

5 Fair market value of account

$

Form 5498

OMB No. 1545-0747

7 IRA SEP SIMPLE

8 SEP contributions 9 SIMPLE contributions

$ $

10 Roth IRA contributions

$

Roth IRA

Life insurance cost

included in box 1

6

$

4 Recharacterized contributions

$

2003

11 Check if RMD

for 2004
Instructions for Trustees and Issuers

We now provide general and specific form

instructions as separate products. The products

you should use for 2003 are the General

Instructions for Forms 1099, 1098, 5498, and

W-2G and the separate specific instructions for

each information return you file. Specific

information needed to complete this form is given

in the 2003 Instructions for Forms 1099-R and

5498. To order these instructions and additional

forms, call 1-800-TAX-FORM (1-800-829-3676).

Due dates. Furnish Copy B of this form to the

participant by May 31, 2004, but furnish fair

market value information by February 2, 2004.

File Copy A of this form with the IRS by

May 31, 2004.

Caution: Because the IRS processes paper forms

by machine (optical character recognition

equipment), you cannot file with the IRS Forms

1096, 1098, 1099, or 5498 that you print from the

IRS website.