VOID CORRECTED

IRA

Contribution

Information

2828

SIMPLE contributions

IRA contributions (other OMB No. 1545-0747

than amounts in boxes

2-4, 8-10, 13a, 14a, and

15a)

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

$

2 Rollover 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

15a Other contributions

4

$ $

Form 5498

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

Copy A

File with Form 1096.

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2009 General

Instructions for

Forms 1099,

1098, 3921,

3922, 5498, and

W-2G.

For

Internal Revenue

Service Center

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

11

Account number (see instructions)

IRA SEP SIMPLE Roth IRA

Check if RMD for 2010

RMD amount

Code

$

10 Roth IRA contributions

12a RMD date 12b

$

13c

$

15bCode

2009

14bCode

$

$
(keep for your records)

Copy B

For

Participant

(if checked)

This information

is being

provided to

the Internal

Revenue

Service.

CORRECTED

IRA

Contribution

Information

SIMPLE contributions

IRA contributions (other OMB No. 1545-0747

than amounts in boxes

2-4, 8-10, 13a, 14a, and

15a)

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

$

2 Rollover 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

15a Other contributions

4

$ $

Form 5498

Form 5498 Department of the Treasury - Internal Revenue Service

11

Account number (see instructions)

IRA SEP SIMPLE Roth IRA

Check if RMD for 2010

RMD amount

Code

$

10 Roth IRA contributions

12a RMD date 12b

$

13c

$

15bCode

2009

14bCode

$

$
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, required minimum

distributions (RMDs), and the fair market value (FMV) of the account. For

information about IRAs, see Pubs. 590 and 560.

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 2009 you made in 2009 and

through April 15, 2010. 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, 14a, and 15a.

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 2009. 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 8. Shows SEP contributions made in 2009, including contributions made in

2009 for 2008, but not including contributions made in 2010 for 2009. If made

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

Box 9. Shows SIMPLE contributions made in 2009. 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 2009 and through April 15,

2010. Do not deduct on your income tax return.

Instructions for 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 an RMD for 2010. An RMD may be

required even if the box is not checked. If you do not take the RMD for 2010,

you are subject to a 50% excise tax on the amount not distributed. See Pub.

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 2009. Use Form 8606 to figure the taxable amount.

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

distributed to avoid the 50% excise tax on the undistributed amount for 2010.

Box 12b. Shows the amount of the RMD for 2010. If box 11 is checked and

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

amount or offer to calculate the amount in a separate statement by February 1,

2010.

Box 13a. Shows the amount of any postponed contribution made in 2009 for a

prior year.

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

credited.

Box 13c. For participants who made a postponed contribution due to an

extension of the contribution due date because of a federally designated

disaster, shows the code FD.

For participants who served in designated combat zones and made

postponed contributions, shows the code for the combat zone or hazardous

duty area in which the participant served. The codes are: AF—Allied Force;

JE—Joint Endeavor; EF—Enduring Freedom; and IF—Iraqi Freedom. For

additional information, including a list of locations within the designated combat

zones and qualified hazardous duty areas, see Pub. 3, Armed Forces’ Tax

Guide.

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

distribution or federally designated disaster withdrawal repayment. See Pub.

590 for reporting repayments.

Box 15a. Shows the amount of any catch-up contributions you made in the

case of certain employer bankruptcies in lieu of the higher contribution limit for

individuals who are age 50 or older. See Pub. 590.

Box 15b. Shows the code BK for special catch-up contributions elected by the

participant in certain employer bankruptcies. See Pub. 590.

What’s new. The size of Form 5498 has been increased to allow for separate

entry boxes for information that was previously reported in the blank box to the

left of box 10. See the instructions for boxes 12a–15b below.

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

distribution or code DD for repayment of a federally designated disaster

distribution.

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

See Pub. 560.
VOID CORRECTED

IRA

Contribution

Information

SIMPLE contributions

IRA contributions (other OMB No. 1545-0747

than amounts in boxes

2-4, 8-10, 13a, 14a, and

15a)

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

$

2 Rollover 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

15a Other contributions

4

$ $

Form 5498

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

Copy C

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2009 General

Instructions for

Forms 1099,

1098, 3921,

3922, 5498, and

W-2G.

For

Trustee or Issuer

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

11

Account number (see instructions)

IRA SEP SIMPLE Roth IRA

Check if RMD for 2010

RMD amount

Code

$

10 Roth IRA contributions

12a RMD date 12b

$

13c

$

15bCode

2009

14bCode

$

$
Instructions for Trustees and Issuers

We provide general and specific form instructions

as separate products. The products you should

use for 2009 are the General Instructions for

Forms 1099, 1098, 3921, 3922, 5498, and W-2G

and the 2009 Instructions for Forms 1099-R 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 June 1, 2010, but furnish fair

market value information and RMD if applicable

by February 1, 2010.

File Copy A of this form with the IRS by

June 1, 2010. If you file electronically, you must

have software that generates a file according to

the specifications in Pub. 1220, Specifications for

Filing Forms 1098, 1099, 3921, 3922, 5498, and

W-2G Electronically. IRS does not provide a 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 reporting

on Form 5498, call the information reporting

customer service site toll free at 1-866-455-7438

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

equipment, call 304-267-3367 (not toll free).