Additional Taxes on Qualified Plans OMB No. 1545-0203 5329 (Including IRAs) and Other Tax-Favored Accounts Form

Department of the Treasury

Internal Revenue Service

Attachment

Sequence No. 29

 Attach to Form 1040.

Name of individual subject to additional tax. If married filing jointly, see instructions. Your social security number

Home address (number and street), or P.O. box if mail is not delivered to your home

City, town or post office, state, and ZIP code If this is an amended

return, check here 

Enter your excess contributions from line 16 of your 2003 Form 5329 (see instructions). If zero,

go to line 15

13

14 14

If your traditional IRA contributions for 2004 are less than your

maximum allowable contribution, see instructions. Otherwise, enter -0-

15

2004 traditional IRA distributions included in income (see instructions)

15

2004 distributions of prior year excess contributions (see instructions)

Add lines 10, 11, and 12

Prior year excess contributions. Subtract line 13 from line 9. If zero or less, enter -0-

Excess contributions for 2004 (see instructions)

Additional Tax on Early Distributions

Complete this part if you took a taxable distribution, before you reached age 591⁄2 , from a qualified retirement plan (including

an IRA) or modified endowment contract (unless you are reporting this tax directly on Form 1040—see above). You may also

have to complete this part to indicate that you qualify for an exception to the additional tax on early distributions or for certain

Roth IRA distributions (see instructions).

1 Early distributions included in income. For Roth IRA distributions, see instructions 1

Early distributions included on line 1 that are not subject to the additional tax (see instructions).

Enter the appropriate exception number from the instructions: 

2

2

3 Amount subject to additional tax. Subtract line 2 from line 1 3

4 Additional tax. Enter 10% (.10) of line 3. Include this amount on Form 1040, line 59 4

For Paperwork Reduction Act Notice, see page 5 of the instructions. Cat. No. 13329Q Form 5329 (2004)

Apt. no.

Part I

Part II

If you only owe the additional 10% tax on early distributions, you may be able to report this tax directly

on Form 1040, line 59, without filing Form 5329. See the instructions for Form 1040, line 59.

Fill in Your Address Only

If You Are Filing This

Form by Itself and Not

With Your Tax Return 

Caution: If any part of the amount on line 3 was a distribution from a SIMPLE IRA, you may have

to include 25% of that amount on line 4 instead of 10% (see instructions).

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8

6

7

8

Additional Tax on Certain Distributions From Education Accounts

Distributions included in income from Coverdell ESAs and QTPs

9

10

Distributions included on line 5 that are not subject to the additional tax (see instructions)

11

Amount subject to additional tax. Subtract line 6 from line 5

12

Additional tax. Enter 10% (.10) of line 7. Include this amount on Form 1040, line 59

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10

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Part III Additional Tax on Excess Contributions to Traditional IRAs

Complete this part if you contributed more to your traditional IRAs for 2004 than is allowable or you had an amount

on line 17 of your 2003 Form 5329.

Total excess contributions. Add lines 14 and 15 16

Additional tax. Enter 6% (.06) of the smaller of line 16 or the value of your traditional IRAs on December

31, 2004 (including 2004 contributions made in 2005). Include this amount on Form 1040, line 59 17

16

17

Complete this part if you included an amount in income, on Form 1040, line 21, from a Coverdell education savings

account (ESA) or a qualified tuition program (QTP).

 See separate instructions.

13

(99)

2004

Part IV Additional Tax on Excess Contributions to Roth IRAs

Enter your excess contributions from line 24 of your 2003 Form 5329 (see instructions). If zero, go to line 23

If your Roth IRA contributions for 2004 are less than your maximum

allowable contribution, see instructions. Otherwise, enter -0-

18 18

19

Complete this part if you contributed more to your Roth IRAs for 2004 than is allowable or you had an amount on line

25 of your 2003 Form 5329.

20 2004 distributions from your Roth IRAs (see instructions)

21 Add lines 19 and 20

22 Prior year excess contributions. Subtract line 21 from line 18. If zero or less, enter -0-

23 Excess contributions for 2004 (see instructions)

24 Total excess contributions. Add lines 22 and 23

Additional tax. Enter 6% (.06) of the smaller of line 24 or the value of your Roth IRAs on December 31,

2004 (including 2004 contributions made in 2005). Include this amount on Form 1040, line 59

25

21

22

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25

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Form 5329 (2004) Page 2

Additional Tax on Excess Accumulation in Qualified Retirement Plans (Including IRAs)

Minimum required distribution for 2004 (see instructions) 44

Amount actually distributed to you in 2004 45

Subtract line 45 from line 44. If zero or less, enter -0- 46

Additional tax. Enter 50% (.50) of line 46. Include this amount on Form 1040, line 59 47

Under penalties of perjury, I declare that I have examined this form, including accompanying schedules and statements, and to the best of my knowledge

and belief, it is true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Your signature Date

Date Preparer’s SSN or PTIN Preparer’s

signature

Check if selfemployed

Firm’s name (or yours

if self-employed),

address, and ZIP code

EIN

Phone no.

 





Signature. Complete only if you are filing this form by itself and not with your tax return.

Please

Sign

Here

Paid

Preparer’s

Use Only

Additional Tax on Excess Contributions to Archer MSAs

Enter the excess contributions from line 40 of your 2003 Form 5329 (see instructions). If zero,

go to line 39

Additional tax. Enter 6% (.06) of the smaller of line 40 or the value of your Archer MSAs on

December 31, 2004 (including 2004 contributions made in 2005). Include this amount on Form

1040, line 59

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47

34

39

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Part VI

Part V

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35

Additional Tax on Excess Contributions to Coverdell ESAs

Enter the excess contributions from line 32 of your 2003 Form 5329 (see instructions). If zero,

go to line 31

If the contributions to your Coverdell ESAs for 2004 were less than the

maximum allowable contribution, see instructions. Otherwise, enter -0-

36

37

26

35

39

40

41

44

45

46

36

37

38

If the contributions to your Archer MSAs for 2004 are less than the

maximum allowable contribution, see instructions. Otherwise, enter -0-

2004 distributions from your Archer MSAs from Form 8853, line 10

Add lines 35 and 36

Prior year excess contributions. Subtract line 37 from line 34. If zero or less, enter -0-

Excess contributions for 2004 (see instructions)

Total excess contributions. Add lines 38 and 39

Complete this part if you or your employer contributed more to your Archer MSAs for 2004 than is allowable or you

had an amount on line 41 of your 2003 Form 5329.

Complete this part if you did not receive the minimum required distribution from your qualified retirement plan.

Complete this part if the contributions to your Coverdell ESAs for 2004 were more than is allowable or you had an

amount on line 33 of your 2003 Form 5329.

28 2004 distributions from your Coverdell ESAs (see instructions)

29 Add lines 27 and 28 29

30 Prior year excess contributions. Subtract line 29 from line 26. If zero or less, enter -0- 30

27

28

31 Excess contributions for 2004 (see instructions) 31

32 Total excess contributions. Add lines 30 and 31 32

33 Additional tax. Enter 6% (.06) of the smaller of line 32 or the value of your Coverdell ESAs on

December 31, 2004 (including 2004 contributions made in 2005). Include this amount on Form

1040, line 59 33

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41

Form 5329 (2004)

( )

Additional Tax on Excess Contributions to Health Savings Accounts (HSAs)

Complete this part if contributions to your HSAs were more than is allowable.

Part VII

42 Excess contributions for 2004 (see instructions) 42

43

Additional tax. Enter 6% (.06) of the smaller of line 42 or the value of your HSAs on December 31, 2004

(including 2004 contributions made in 2005). Include this amount on Form 1040, line 59

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Part VIII