SIMPLE contributions

$

Roth IRA conversion Recharacterized contributions

amount

3

PARTICIPANT’S social security

number

TRUSTEE’S or ISSUER’S federal

identification no.

5 Fair market value of account 6 Life insurance cost included in

box 1

$ $

PARTICIPANT’S name

8 SEP contributions

7

$

9

Street address (including apt. no.)

City, state, and ZIP code 13a Postponed contribution 13b Year

$

14a Repayments

4

$ $

Form 5498

Form 5498 Cat. No. 50010C Department of the Treasury - Internal R

File wi

For 

and 

Re

Not

20

Instr

I

Intern

Ser

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

11

Account number (see instructions)

IRA SEP SIMPLE Roth IRA

Check if RMD for 2011

RMD amount

Code

$

10 Roth IRA contributions

12a RMD date 12b

$

13c

14bCode

$

$
(keep for your records)

This 

f

SIMPLE contributions

$

Roth IRA conversion Recharacterized contributions

amount

3

PARTICIPANT’S social security

number

TRUSTEE’S or ISSUER’S federal

identification no.

5 Fair market value of account 6 Life insurance cost included in

box 1

$ $

PARTICIPANT’S name

8 SEP contributions

7

$

9

Street address (including apt. no.)

City, state, and ZIP code 13a Postponed contribution 13b Year

$

14a Repayments

4

$ $

Form 5498

Form 5498 Department of the Treasury - Internal R

11

Account number (see instructions)

IRA SEP SIMPLE Roth IRA

If checked, required minimum

distribution for 2011.

RMD amount

Code

$

10 Roth IRA contributions

12a RMD date 12b

$

13c

14bCode

$

$
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 FMV of all investments in your account at year end. However,

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

Box 1. Shows traditional IRA contributions for 2010 you made in 2010 and

through April 15, 2011. 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, 8–10, 13a, and 14a.

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

IRA, or a qualified rollover contribution (including a military death gratuity, SGLI

payment, qualified settlement income, or airline payments) to a Roth IRA you

made in 2010. 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 to figure the taxable amount. If property was rolled over, see Pub.

590. For a qualified rollover to a Roth IRA, also see Pub. 590.

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

Box 10. Shows Roth IRA contributions you made in 2010 and th

2011. Do not deduct on your income tax return.

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 an RMD for 2011. A

required even if the box is not checked. If you do not take the RM

you are subject to a 50% excise tax on the amount not distribute

590 for details.

Account number. May show an account or other unique number the trustee

assigned to distinguish your account.

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

IRA to a Roth IRA in 2010. Use Form 8606 to figure the taxable amount.

Box 12a. Shows the date by which the RMD amount in box 12b 

distributed to avoid the 50% excise tax on the undistributed amo

Box 12b. Shows the amount of the RMD for 2011. If box 11 is ch

there is no amount in this box, the trustee or issuer must provide 

amount or offer to calculate the amount in a separate statement 

2011.

Box 13a. Shows the amount of any postponed contribution mad

prior year.

Box 13b. Shows the year to which the postponed contribution in 

credited.

Box 13c. For participants who made a postponed contribution d

extension of the contribution due date because of a federally des

disaster, shows the code FD.

For participants who served in designated combat zones and 

postponed contributions, shows the code for the combat zone o

duty area in which the participant served. The codes are: AF—Al

JE—Joint Endeavor; EF—Enduring Freedom; and IF—Iraqi Freed

additional information, including a list of locations within the des

zones, see Pub. 3, Armed Forces’ Tax Guide.

Box 14a. Shows the amount of any repayment of a qualified rese

distribution or federally designated disaster withdrawal repayme

590 for reporting repayments.

Box 14b. Shows the code QR for the repayment of a qualified re

distribution or code DD for repayment of a federally designated d

distribution.

However, the issuer has reported your complete identification number to the

IRS, and, where applicable, to state and/or local governments.
SIMPLE contributions

$

Roth IRA conversion Recharacterized contributions

amount

3

PARTICIPANT’S social security

number

TRUSTEE’S or ISSUER’S federal

identification no.

5 Fair market value of account 6 Life insurance cost included in

box 1

$ $

PARTICIPANT’S name

8 SEP contributions

7

$

9

Street address (including apt. no.)

City, state, and ZIP code 13a Postponed contribution 13b Year

$

14a Repayments

4

$ $

Form 5498

Form 5498 Department of the Treasury - Internal R

For 

and 

Re

Noti

20

Instr

I

Truste

11

Account number (see instructions)

IRA SEP SIMPLE Roth IRA

Check if RMD for 2011

RMD amount

Code

$

10 Roth IRA contributions

12a RMD date 12b

$

13c

14bCode

$

$
Instructions for Forms 1099R and 5498. To order

these instructions and additional forms, visit the

IRS website at www.irs.gov or call

1-800-TAX-FORM (1-800-829-3676).

Due dates. Furnish Copy B of this form to the

participant by May 31, 2011, but furnish fair

market value information and RMD if applicable

by January 31, 2011.

Filing Forms 1098, 1099, 3921, 3922, 54

and W-2G Electronically. IRS does not p

fill-in form option.

Caution: Because paper forms are scanned

during processing, you cannot file with the IRS

Forms 1096, 1098, 1099, 3921, 3922, or 5498 that

you print from the IRS website.

Need help? If you have questions about 

on Form 5498, call the information repor

customer service site toll free at 1-866-4

or 304-263-8700 (not toll free). For TTY/T

equipment, call 304-579-4827 (not toll fr

hours of operation are Monday through 

from 8:30 a.m. to 4:30 p.m., Eastern tim