Form 5329

Department of the Treasury 

Internal Revenue Service (99)

Additional Taxes on Qualified Plans 

(Including IRAs) and Other Tax-Favored Accounts

▶ Attach to Form 1040 or Form 1040NR. 

▶ Information about Form 5329 and its separate instructions is at www.irs.gov/form5329.

OMB No. 1545-0074

2012

Attachment 

Sequence No. 29

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

Fill in Your Address Only 

If You Are Filing This 

Form by Itself and Not 

With Your Tax Return ▲

Home address (number and street), or P.O. box if mail is not delivered to your home Apt. no.

City, town or post office, state, and ZIP code. If you have a foreign address, also complete 

the spaces below (see instructions). If this is an amended 

return, check here ▶

Foreign country name Foreign province/state/county Foreign postal code

If you only owe the additional 10% tax on early distributions, you may be able to report this tax directly on Form 1040, line 58, or 

Form 1040NR, line 56, without filing Form 5329. See the instructions for Form 1040, line 58, or for Form 1040NR, line 56.

Part I 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 or Form 1040NR—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 

2 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 

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 58, or Form 1040NR, line 56 4 

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).

Part II Additional Tax on Certain Distributions From Education Accounts

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

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

5 Distributions included in income from Coverdell ESAs and QTPs . . . . . . . . . . . . 5 

6 Distributions included on line 5 that are not subject to the additional tax (see instructions) . . . 6 

7 Amount subject to additional tax. Subtract line 6 from line 5 . . . . . . . . . . . . . 7 

8 Additional tax. Enter 10% (.10) of line 7. Include this amount on Form 1040, line 58, or Form 1040NR, line 56 8 

Part III Additional Tax on Excess Contributions to Traditional IRAs

Complete this part if you contributed more to your traditional IRAs for 2012 than is allowable or you had an amount on line 

17 of your 2011 Form 5329.

9 Enter your excess contributions from line 16 of your 2011 Form 5329 (see instructions). If zero, go to line 15 . 9 

10 If your traditional IRA contributions for 2012 are less than your 

maximum allowable contribution, see instructions. Otherwise, enter -0- 10 

11 2012 traditional IRA distributions included in income (see instructions) . 11 

12 2012 distributions of prior year excess contributions (see instructions) . 12 

13 Add lines 10, 11, and 12 . . . . . . . . . . . . . . . . . . . . . . . . . 13 

14 Prior year excess contributions. Subtract line 13 from line 9. If zero or less, enter -0- . . . . . 14 

15 Excess contributions for 2012 (see instructions) . . . . . . . . . . . . . . . . . 15 

16 Total excess contributions. Add lines 14 and 15 . . . . . . . . . . . . . . . . . 16 

17 Additional tax. Enter 6% (.06) of the smaller of line 16 or the value of your traditional IRAs on December 31, 2012 

(including 2012 contributions made in 2013). Include this amount on Form 1040, line 58, or Form 1040NR, line 56 . 17 

Part IV Additional Tax on Excess Contributions to Roth IRAs

Complete this part if you contributed more to your Roth IRAs for 2012 than is allowable or you had an amount on line 25 of your 2011 Form 5329.

18 Enter your excess contributions from line 24 of your 2011 Form 5329 (see instructions). If zero, go to line 23 18 

19 If your Roth IRA contributions for 2012 are less than your maximum 

allowable contribution, see instructions. Otherwise, enter -0- . . . . 19 

20 2012 distributions from your Roth IRAs (see instructions) . . . . . 20 

21 Add lines 19 and 20 . . . . . . . . . . . . . . . . . . . . . . . . . . 21 

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

23 Excess contributions for 2012 (see instructions) . . . . . . . . . . . . . . . . . 23 

24 Total excess contributions. Add lines 22 and 23 . . . . . . . . . . . . . . . . . 24 

25 Additional tax. Enter 6% (.06) of the smaller of line 24 or the value of your Roth IRAs on December 31, 2012

(including 2012 contributions made in 2013). Include this amount on Form 1040, line 58, or Form 1040NR, line 56 . 25 

For Privacy Act and Paperwork Reduction Act Notice, see your tax return instructions. Cat. No. 13329Q Form 5329 (2012) 
Form 5329 (2012) Page 2 

Part V Additional Tax on Excess Contributions to Coverdell ESAs

Complete this part if the contributions to your Coverdell ESAs for 2012 were more than is allowable or you had an amount 

on line 33 of your 2011 Form 5329.

26 Enter the excess contributions from line 32 of your 2011 Form 5329 (see instructions). If zero, go to line 31 26 

27 If the contributions to your Coverdell ESAs for 2012 were less than the 

maximum allowable contribution, see instructions. Otherwise, enter -0- 27 

28 2012 distributions from your Coverdell ESAs (see instructions) . . . 28 

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 

31 Excess contributions for 2012 (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, 2012 (including 2012 contributions made in 2013). Include this amount on Form

1040, line 58, or Form 1040NR, line 56 . . . . . . . . . . . . . . . . . . . . 33 

Part VI Additional Tax on Excess Contributions to Archer MSAs

Complete this part if you or your employer contributed more to your Archer MSAs for 2012 than is allowable or you had an 

amount on line 41 of your 2011 Form 5329.

34 Enter the excess contributions from line 40 of your 2011 Form 5329 (see instructions). If zero, go to line 39 34 

35 If the contributions to your Archer MSAs for 2012 are less than the 

maximum allowable contribution, see instructions. Otherwise, enter -0- 35 

36 2012 distributions from your Archer MSAs from Form 8853, line 8 . . 36 

37 Add lines 35 and 36 . . . . . . . . . . . . . . . . . . . . . . . . . . 37 

38 Prior year excess contributions. Subtract line 37 from line 34. If zero or less, enter -0-. . . . . 38 

39 Excess contributions for 2012 (see instructions) . . . . . . . . . . . . . . . . . 39 

40 Total excess contributions. Add lines 38 and 39 . . . . . . . . . . . . . . . . . 40 

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

December 31, 2012 (including 2012 contributions made in 2013). Include this amount on Form

1040, line 58, or Form 1040NR, line 56 . . . . . . . . . . . . . . . . . . . . 41 

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

Complete this part if you, someone on your behalf, or your employer contributed more to your HSAs for 2012 than is 

allowable or you had an amount on line 49 of your 2011 Form 5329.

42 Enter the excess contributions from line 48 of your 2011 Form 5329. If zero, go to line 47 . . . 42 

43 If the contributions to your HSAs for 2012 are less than the maximum 

allowable contribution, see instructions. Otherwise, enter -0- . . . . 43 

44 2012 distributions from your HSAs from Form 8889, line 16 . . . . 44 

45 Add lines 43 and 44 . . . . . . . . . . . . . . . . . . . . . . . . . . 45 

46 Prior year excess contributions. Subtract line 45 from line 42. If zero or less, enter -0-. . . . . 46 

47 Excess contributions for 2012 (see instructions) . . . . . . . . . . . . . . . . . 47 

48 Total excess contributions. Add lines 46 and 47 . . . . . . . . . . . . . . . . . 48 

49 Additional tax. Enter 6% (.06) of the smaller of line 48 or the value of your HSAs on December 31, 2012 

(including 2012 contributions made in 2013). Include this amount on Form 1040, line 58, or Form 1040NR, line 56 49 

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

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

50 Minimum required distribution for 2012 (see instructions) . . . . . . . . . . . . . . 50 

51 Amount actually distributed to you in 2012 . . . . . . . . . . . . . . . . . . . 51 

52 Subtract line 51 from line 50. If zero or less, enter -0- . . . . . . . . . . . . . . . 52 

53 Additional tax. Enter 50% (.50) of line 52. Include this amount on Form 1040, line 58, or Form 1040NR, line 56 53 

Sign Here Only If You 

Are Filing This Form by 

Itself and Not With Your 

Tax Return

Under penalties of perjury, I declare that I have examined this form, including accompanying attachments, 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.

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Your signature ▲Date

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self-employed

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Firm’s name ▶ Firm's EIN ▶

Firm's address ▶ Phone no.

Form 5329 (2012)