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

$

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 (see instructions)

Form 5498 Department of the Treasury - In

2828

Cat. No. 50010C

F

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 

4 Recharacterized contributions

$

11 Check if RMD

for 2006

2005
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 (see instructions)

Form 5498 Department of the Treasury - In

(keep for your records)

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

$

11 If checked, required

minimum distribution 

for 2006

2005
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 am

cost of life insurance. Subtract this amount from you

contribution included in box 1 to compute your IRA 

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 2005 you made in 2005

and through April 17, 2006. 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 2005. 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 F

Box 8. Shows SEP contributions made in 2005, incl

made in 2005 for 2004, but not including contributio

2005. If made by your employer, do not deduct on y

return. If you made the contributions as a self-emplo

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

Box 9. Shows SIMPLE contributions made in 2005. 

employer, do not deduct on your income tax return. 

contributions as a self-employed person (or partner)

deductible. See Pub. 560.

Box 10. Shows Roth IRA contributions you made in 

April 17, 2006. Do not deduct on your income tax re

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

IRA to a Roth IRA in 2005. 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 requ

distribution (RMD) for 2006. An RMD may be require

not checked. The amount, or offer to compute the a

the RMD will be furnished to you by January 31 eith

the blank box to the left of box 10) or in a separate 

not take the RMD for 2006, you are subject to a 50% 

amount not distributed. See Pub. 590 for details.

the FMV on the date of death. If the FMV shown is z

the executor or administrator of the estate may requ

value from the financial institution.

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

payer assigned to distinguish your account.
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 (see instructions)

Form 5498 Department of the Treasury - In

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

$

11 Check if RMD

for 2006

2005
Instructions for Trustees and Issuers

We provide general and specific form instructions

as separate products. The products you should

use for 2005 are the General Instructions for

Forms 1099, 1098, 5498, and W-2G and the 2005

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 

participant by May 31, 2006, but fu

market value information and RMD 

by January 31, 2006.

File Copy A of this form with the I

May 31, 2006.

Caution: Because paper forms are 

during processing, you cannot file w

Forms 1096, 1098, 1099, or 5498 th

from the IRS website.