Additional Taxes Attributable to Qualified OMB No. 1545-0203

Retirement Plans (Including IRAs), Annuities,

Modified Endowment Contracts, and MSAs

Form 5329

Department of the Treasury

Internal Revenue Service

Attachment

Sequence No. 29

(Under Sections 72, 4973, and 4974 of the Internal Revenue Code)

© Attach to Form 1040. See separate instructions.

Name of individual subject to additional tax. (If married filing jointly, see page 2 of the instructions.) Your social security number

Home address (number and street), or P.O. box if mail is not delivered to your home

City, town or post office, state, and ZIP code If this is an amended

return, check here ©

Tax on Excess Contributions to Individual Retirement Arrangements

Complete this part if, either in this year or in earlier years, you contributed more to your IRA than is or was allowable and you have

an excess contribution subject to tax.

5

Excess contributions for 1997 (see page 3 of the instructions). Do not include this amount on

Form 1040, line 23

5

6

6 Earlier year excess contributions not previously eliminated (see page

3 of the instructions)

7 Contribution credit. If your actual contribution for 1997 is less than

your maximum allowable contribution, see page 3 of the instructions;

otherwise, enter -0- 7

8

8 1997 distributions from your IRA account that are includible in taxable

income

9 1996 tax year excess contributions (if any) withdrawn after the due

date (including extensions) of your 1996 income tax return, and 1995

and earlier tax year excess contributions withdrawn in 1997 9

10 Add lines 7, 8, and 9 10

Adjusted earlier year excess contributions. Subtract line 10 from line 6. Enter the result, but not

less than zero

11

11

12 Total excess contributions. Add lines 5 and 11 12

13 Tax due. Enter the smaller of 6% (.06) of line 12 or 6% (.06) of the value of your IRA on the

last day of 1997. Also enter this amount on Form 1040, line 50 13

Tax on Early Distributions

Complete this part if a taxable distribution was made from your qualified retirement plan (including an IRA), annuity contract, or

modified endowment contract before you reached age 591⁄2 (or was incorrectly indicated as such on your Form 1099-R—see

instructions). Note: You must include the amount of the distribution on line 15b or 16b of Form 1040.

1 Early distributions included in gross income (see page 2 of the instructions) 1

Distributions excepted from additional tax (see page 2 of the instructions). Enter appropriate

exception number from instructions ©

2

2

3 Amount subject to additional tax. Subtract line 2 from line 1 3

4 Tax due. Multiply line 3 by 10% (.10). Enter here and on Form 1040, line 50 4

For Paperwork Reduction Act Notice, see page 4 of separate instructions. Cat. No. 13329Q Form 5329 (1997)

Apt. no.

Part I

Part II

If you are subject to the 10% tax on early distributions only, see Who

Must File in the instructions before continuing. You may be able to

report this tax directly on Form 1040 without filing Form 5329.

Fill in Your Address Only

If You Are Filing This

Form by Itself and Not

With Your Tax Return

Caution: If any amount on line 3 was a distribution from a SIMPLE retirement plan, you must multiply that distribution by 25%

(.25) instead of 10%. See instructions for more information.

97
Form 5329 (1997) Page 2

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

16 Minimum required distribution (see page 4 of the instructions) 16

17 Amount actually distributed to you 17

18 Subtract line 17 from line 16. If line 17 is more than line 16, enter -0- 18

19 Tax due. Multiply line 18 by 50% (.50). Enter here and on Form 1040, line 50 19

Under penalties of perjury, I declare that I have examined this form, including accompanying schedules and statements, 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.

Your signature Date

Date Preparer’s social security no. Preparer’s

signature

Check if selfemployed ©

Firm’s name (or yours,

if self-employed) and

address

EIN ©

ZIP code ©

© ©

©

©

Part IV

Part III

Signature. Complete ONLY if you are filing this form by itself and not with your tax return.

Please

Sign

Here

Paid

Preparer’s

Use Only

Tax on Excess Contributions to Medical Savings Accounts

Excess contributions for 1997 (see page 4 of the instructions). Do not include this amount on

Form 1040, line 24

Tax due. Enter the smaller of 6% (.06) of line 14 or 6% (.06) of the value of your MSA on the

last day of 1997. Also enter this amount on Form 1040, line 50

14

15

14

15