[voip

[J CORRECTED

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

1 Regular IRA contributions
made :n 1991 and 1992 for

(OMBNo. 1845.0747 |

1991 individual
$ O Retirement
2 Rollover IRA contributions 1991 Arrangement
Information
$
TRUSTEE'S or ISSUER'S Federal identification no] PARTICIPANT'S social security number | 3 Life insurance cost included in Box 1 Copy ©
$ For
PARTICIPANT'S name 4 Fair market value of account Trustee
or Issuer

Street address (including apt. no.)

City, state, and ZIP code

$

For Paperwork

Reduction Act
Notice and
instructions for

completing this
form, see

Account number (optional)

Instructions for
Forms 1099, 1098,
5498, and W-2G.

Form 5498

{J voip

(_] CORRECTED

Department of the Treasury - Internal Revenue Service

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

1 Regular IRA contributions
made in 1991 and 1992 for

OMB No. 1545-0747

Street address (including apt. no.)

City, state, and ZIP code

$

1991 Individual
$ Retirement
2 Rollover IRA contributions 1991 Arrangement
Information
$
‘TRUSTEE'S or ISSUER'S Federal identification no] PARTICIPANT'S social security number | 3 Life insurance cost included in Box 1 Copy Cc
$ For
PARTICIPANT'S name 4 Fair market value of account Trustee
or Issuer

For Paperwork

Reduction Act
Notice and
instructions for

completing this
form, see
instructions for

Account number (optional)

Forms 1099, 1098,
5498, and W-2G.

Form 5498

LJ voip

(J CORRECTED

Department of the Treasury - Internal Revenue Service

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

1 Regular IRA contributions
made in 1991 and 1992 for

OMB No. 1545-0747

City, state, and ZIP code

1991 Individual
$ eB Retirement
2 Rollover IRA contributions, 1991 Arrangement
information
$
TRUSTEE'S or ISSUER'S Federal identification no] PARTICIPANT'S social security number | 3 Life insurance cost included in Box 1 Copy C
$ For
PARTICIPANT'S name 4 Fair market value of account Trustee
or Issuer
$ For Paperwork
Street address (including apt. no.) Reduction Act
Notice and

instructions for

completing this
form, see
instructions for

Account nurnber (optional)

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

Form 5498

Department of the Treasury - Interna! Revenue Service


Instructions to Participant

The information in Boxes 1, 2, 3, and 4 has been submitted
to the Internal Revenue Service by the trustee or issuer of
your individual retirement arrangement (IRA) to report
regular or rollover contributions made to your IRA and the
value of your IRA or simplified employee pension (SEP)
account.

If you or your spouse were an active participant in an
employer’s pension plan, your IRA contributions may not be
deductible. See your Form 1040 or 1040A instructions for
details.

Box 1.—The amount shown is the contributions for 1991
made in 1991 and through Apri! 15, 1992, to an IRA.

Box 2.—This is the amount of any rollover you made in
1991. You must report the total distribution you received
from your IRA on the appropriate line of your income tax
return. Subtract the part of the distribution that was rolled
over and enter the taxable remainder on the appropriate
line of your income tax return. But if you have ever made
any nondeductible contributions to your IRA, use Form

Instructions to Participant

The information in Boxes 1, 2, 3, and 4 has been submitted
to the Internal Revenue Service by the trustee or issuer of
your individual retirement arrangement (IRA) to report
regular or rollover contributions made to your IRA and the
value of your IRA or simplified employee pension (SEP)
account.

If you or your spouse were an active participant in an
employer's pension plan, your IRA contributions may not be
deductible. See your Form 1040 or 1040A instructions for
details.

Box 1.—The amount shown is the contributions for 1991
made in 1991 and through April 15, 1992, to an IRA.

Box 2.—This is the amount of any rollover you made in
1991. You must report the total distribution you received
from your IRA on the appropriate line of your income tax
return. Subtract the part of the distribution that was rolled
over and enter the taxable remainder on the appropriate
line of your income tax return. But if you have ever made
any nondeductible contributions to your IRA, use Form

Instructions to Participant

The information in Boxes 1, 2, 3, and 4 has been submitted
to the Internal Revenue Service by the trustee or issuer of
your individual retirement arrangement (IRA) to report
regular or rollover contributions made to your IRA and the
value of your IRA or simplified employee pension (SEP)
account.

If you or your spouse were an active participant in an
employer’s pension plan, your IRA contributions may not be
deductible. See your Form 1040 or 1040A instructions for
details.

Box 1.—The amount shown is the contributions for 1991
made in 1991 and through April 15, 1992, to an IRA.

Box 2.—This is the amount of any rollover you made in
1991. You must report the total distribution you received
from your IRA on the appropriate line of your income tax
return. Subtract the part of the distribution that was rolled
over and enter the taxable remainder on the appropriate
line of your income tax return. But if you have ever made
any nondeductible contributions to your IRA, use Form

8606, Nondeductible IRA Contributions, IRA Basis, and
Nontaxable IRA Distributions, to figure the taxable amount.
If property was rolled over, see Pub. 590, Individual
Retirement Arrangements (IRAs).

Box 3.—For endowment contracts only, this is the amount
allocable to the cost of life insurance. Subtract this amount
from your allowable IRA contribution included in Box 1 to
compute the amount allowable for your IRA deduction.

Box 4.—This is tne fair market value (FMV) of your
account at the end of the year. However, if a decedent is
shown as the participant on this form, it may be the FMV at
date of death. If a decedent's name is shown as the
participant and the FMV shown is -0-, the executor or
administrator of the decedent's estate may request a
date-of-death valuation from the financial institution.

The trustee or issuer of the plan may use the other boxes on
this form to give you more information about your IRA.

You are not required to attach a copy of Form 5498 to your
income tax return. Keep this form for your records. For
more information about IRAs, see Pub. 590.

8606, Nondeductible IRA Contributions, IRA Basis, and
Nontaxable IRA Distributions, to figure the taxable amount.
lf property was rolled over, see Pub. 590, Individual
Retirement Arrangements (IRAs).

Box 3.—For endowment contracts only, this is the amount
allocable to the cost of life insurance. Subtract this amount
from your allowable IRA contribution included in Box 1 to
compute the amount allowable for your IRA deduction.

Box 4.—This is the fair market value (FMV) of your
account at the end of the year. However, if a decedent is
shown as the participant on this form, it may be the FMV at
date of death. If a decedent’s name is shown as the
participant and the FMV shown is -O-, the executor or
administrator of the decedent's estate may request a
date-of-death valuation from the financial institution.

The trustee or issuer of the plan may use the other boxes on
this form to give you more information about your IRA.

You are not required to attach a copy of Form 5498 to your
income tax return. Keep this form for your records. For
more information about IRAs, see Pub. 590.

8606, Nondeductible IRA Contributions, IRA Basis, and
Nontaxable IRA Distributions, to figure the taxable amount.
lf property was rolled over, see Pub. 590, Individual
Retirement Arrangements (IRAs).

Box 3.—For endowment contracts only, this is the amount
allocable to the cost of life insurance. Subtract this amount
from your allowable IRA contribution included in Box 1 to
compute the amount allowable for your IRA deduction.

Box 4.—This is the fair market value (FMV) of your
account at the end of the year. However, if a decedent is
shown as the participant on this form, it may be the FMV at
date of death. If a decedent's name is shown as the
participant and the FMV shown is -O-, the executor or
administrator of the decedent's estate may request a
date-of-death valuation from the financial institution.

The trustee or issuer of the plan may use the other boxes on
this form to give you more information about your IRA.

You are not required to attach a copy of Form 5498 to your
income tax return. Keep this form for your records. For
more information about IRAs, see Pub. 590.


2628 CL) voip

[_] CORRECTED

‘Type or machine print TRUSTEE'S or ISSUER'S name, street address, city, state,
and ZIP code

1 Regular IRA contributions
made in 1991 and 1992 for
1991

$

2 Rollover IRA contributions

OMB No. 1545-0747

1991

Individual
Retirement
Arrangement
Information

‘Type or machine print PARTICIPANT'S name.

4 Fair market value of account

$

Street address (inclucing apt. no.)

City, state, and ZIP code

Account number (optional)

$
TRUSTEE'S or ISSUER'S Federal identification no] PARTICIPANT'S social security number | 3 Life insurance cost included in Box 1 Copy A
$ For

Internal Revenue
Service Center
File with Form 1096.
For Paperwork
Reduction Act

Notice and
instructions for
completing this
form, see
Instructions for
Forms 1099, 1098,
5498, and W-2G.

Form 5498 Do NOT Cut or Se;

2428 CJ voip

parate Forms on This Page

(] CORRECTED

Department of the Treasury - Internal Revenue Service

‘Type or machine print TRUSTEE’S or ISSUER'S name, street address, city, state,
and ZIP code

1 Regular IRA contributions
made in 1991 and 1992 for

OMB No. 1545-0747

Type or machine print PARTICIPANT'S name

4 Fair market value of account

$

Street address (including apt. no.)

City, state, and ZIP code

Account number (optional)

1991 Individual
$ Retirement
2 Rollover IRA contributions 71991 Arrangement
Information
$
TRUSTEE’S or ISSUER'S Federal identification no] PARTICIPANT'S social security number | 3 Life insurance cost included in Box 1 Copy A
$ For

Internal Revenue
Service Center
File with Form 1096.
For Paperwork
Reduction Act

Notice and
instructions for
completing this
form, see
Instructions for
Forms 1099, 1098,

5498, and W-2G.

Form 5498 Do NOT Cut or Se;

2428 CO voi

parate Forms on This Page

[1 corrEcTED

Department of the Treasury - Internal Revenue Service

Type or machine print TRUSTEE'S or ISSUER'S name, street address, city, state,
and ZIP code

1 Regular IRA contributions

OMB No. 1545-0747

rage in 1991 and 1992 for Individual
$ Retirement
2 Rollover IRA contributions 1991 Arrangement
Information
$
TRUSTEE'S or ISSUER'S Federal identification no] PARTICIPANT'S social security number | 3 Life insurance cost included in Box 1 Copy A
$ For

Type or machine print PARTICIPANT'S name

4 Fair market value of account

$

Internal Revenue
Service Center
File with Form 1096.
For Paperwork

Street address (including apt. no.)

Reduction Act
Notice and

City, state, and ZIP code

instructions for
completing this
form, see

‘Account number (optional)

Instructions for
Forms 1099, 1098,

5498, and W-2G.

Form 5498

Department of the Treasury - Internal Revenue Service




[] CORRECTED (if checked)

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

1 Regular IRA contributions
made in 1991 and 1992 for

OMB No. 1545-0747

1991 Individual
$ Retirement
2 Rollover IRA contributions 1991 Arrangement
Information

$

TRUSTEE'S or ISSUER'S Federal identification no] PARTICIPANT'S social security number | 3 Life insurance cost included in Box 1

$ Copy B
PARTICIPANT'S name 4 Fair market value of account For
Participant

$
The information
Street address (including apt. no.) in Boxes 1,2, 3,
and 4 is being

City, state, and ZIP code

Account number (optional)

furnished to the
Internal Revenue
Service.

Form 5498

Department of the Treasury - Internal Revenue Service

[] CORRECTED (if checked)

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

1 Regular IRA contributions
made in 1991 and 1992 for

OMB No. 1545-0747

City, state, and ZIP code

‘Account number (optional)

1991 Individual!
$ Retirement
2 Rollover IRA contributions 1991 Arrangement
Information

$

TRUSTEE'S or ISSUER'S Federal identification no] PARTICIPANT'S social security number | 3 Life msurance cost included in Box 1

$ Copy B
PARTICIPANT'S name 4 Fair market value of account For
Participant

$
The information
Street address (including apt. no.) in Boxes 1.2.3,
and 4 is being

furnished to the
Internal Revenue
Service.

Form 5498

Department of the Treasury - Internal Revenue Service

[] CORRECTED (if checked)

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

1 Regular IRA contributions
made in 1991 and 1992 for

OMB No. 1545-0747

City, state, and ZIP code

Account number (optional)

1991 Individual
$ Retirement
2 Rollover IRA contributions 1991 Arrangement
Information

$

TRUSTEE'S or ISSUER'S Federal identification no] PARTICIPANT'S social security number | 3 Life insurance cost included in Box 1

$ Copy B
PARTICIPANT'S name 4 Fair market value of account For
Participant

$
The information
Street address (including apt. no.) in Boxes 1, 2, 3,
and 4 is being

furnished to the
Internal Revenue
Service.

Form 5498

Department of the Treasury - Internal Revenue Service