Attention: 

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similar to the official IRS form. The official printed version of Copy A of this IRS form is 

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copy A downloaded from this website; a penalty may be imposed for filing with the IRS 

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Instructions for Certain Information Returns, available at www.irs.gov/form1099, for more 

information about penalties.

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forms.
 

Form 5498

2021

Cat. No. 50010C

IRA 

Contribution 

Information

Copy A

For 

Internal Revenue 

Service Center

Department of the Treasury - Internal Revenue Service

File with Form 1096.

OMB No. 1545-0747

For Privacy Act 

and Paperwork 

Reduction Act 

Notice, see the 

2021 General

Instructions for

Certain

Information

Returns.

2828 VOID CORRECTED

TRUSTEE’S or ISSUER’S name, street address, city or town, state or 

province, country, and ZIP or foreign postal code

TRUSTEE’S or ISSUER’S TIN PARTICIPANT’S TIN

PARTICIPANT’S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

Account number (see instructions)

1 IRA contributions (other 

than amounts in boxes

2–4, 8–10, 13a, and 14a)

$

2 Rollover contributions

$

3 Roth IRA conversion 

amount

$

4 Recharacterized 

contributions

$

5 FMV of account

$

6 Life insurance cost included in 

box 1

$

7 IRA SEP SIMPLE Roth IRA

8 SEP contributions

$

9 SIMPLE contributions

$

10 Roth IRA contributions

$

11 Check if RMD for 2022

12a RMD date 12b RMD amount

$

13a Postponed/late contrib.

$

13b Year 13c Code

14a Repayments

$

14b Code

15a FMV of certain specified 

assets

$

15b Code(s)

Form 5498 www.irs.gov/Form5498

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

Form 5498

2021

IRA 

Contribution 

Information

Copy B

For 

Participant

Department of the Treasury - Internal Revenue Service

This information 

is being 

furnished to 

the IRS.

OMB No. 1545-0747

CORRECTED (if checked)

TRUSTEE’S or ISSUER’S name, street address, city or town, state or 

province, country, and ZIP or foreign postal code

TRUSTEE’S or ISSUER’S TIN PARTICIPANT’S TIN

PARTICIPANT’S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

Account number (see instructions)

1 IRA contributions (other 

than amounts in boxes

2–4, 8–10, 13a, and 14a)

$

2 Rollover contributions

$

3 Roth IRA conversion 

amount

$

4 Recharacterized 

contributions

$

5 FMV of account

$

6 Life insurance cost included in 

box 1

$

7 IRA SEP SIMPLE Roth IRA

8 SEP contributions

$

9 SIMPLE contributions

$

10 Roth IRA contributions

$

11 If checked, required minimum 

distribution for 2022

12a RMD date 12b RMD amount

$

13a Postponed/late contrib.

$

13b Year 13c Code

14a Repayments

$

14b Code

15a FMV of certain specified 

assets

$

15b Code(s)

Form 5498 (keep for your records) www.irs.gov/Form5498
Instructions for Participant

The information on Form 5498 is submitted to the IRS 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-A, 590-B, and 560.

Participant’s taxpayer identification number (TIN). For your protection, this form 

may show only the last four digits of your TIN (SSN, ITIN, ATIN, or EIN). However, the 

trustee or issuer has reported your complete TIN to the IRS.

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

assigned to distinguish your account.

Box 1. Shows traditional IRA contributions for 2021 you made in 2021 and through 

April 18, 2022. These contributions may be deductible on your Form 1040 or 1040-SR. 

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, and 14a.

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 or SGLI payment) to a Roth 

IRA you made in 2021. 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. It does not show any late 

rollover contributions. They are shown in box 13a. See the Form 1040 or 1040-SR 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-A. For a 

qualified rollover to a Roth IRA, also see Pub. 590-A. 

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

to a Roth IRA in 2021. Use Form 8606 to figure the taxable amount.

Box 4. Shows amounts recharacterized from transferring any part of the contribution 

(plus earnings) from one type of IRA to another. See Pub. 590-A.

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 6. Shows for endowment contracts only 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 7. May show the kind of IRA reported on this Form 5498.

Boxes 8 and 9. Show SEP (box 8) and SIMPLE (box 9) contributions made in 2021, 

including contributions made in 2021 for 2020, but not including contributions made in 

2022 for 2021. 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 2021 and through April 18, 2022. 

Do not deduct on your income tax return.

Box 11. If the box is checked, you must take an RMD for 2022. An RMD may be

required even if the box is not checked. If you do not take the RMD for 2022, you are 

subject to a 50% excise tax on the amount not distributed. See Pub. 590-B for details.

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 2022.

Box 12b. Shows the amount of the RMD for 2022. 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 January 31, 2022.

Box 13a. Shows the amount of a late rollover contribution (more than 60 days after 

distribution) made in 2021 and certified by the participant, or a postponed contribution 

made in 2021 for a prior year. This amount is not reported in box 1 or 2.

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

credited. If a late rollover contribution is shown in box 13a, this box will be blank.

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, qualified hazardous duty areas, 

or direct support areas, shows the appropriate code. The codes are: EO13239 for 

Afghanistan and associated direct support areas, EO12744 for the Arabian Peninsula areas, 

PL115-97 for the Sinai Peninsula of Egypt, and EO13119 (or PL106-21) for the Yugoslavia 

operations areas. For additional information, including a list of locations within the 

designated combat zones, qualified hazardous duty areas, and direct support areas, see 

Pub. 3. For updates to the list of locations, go to www.irs.gov/Newsroom/Combat-Zones. 

For a participant who makes a rollover of a qualified plan loan offset, shows the code PO.

For a participant who has used the self-certification procedure for a late rollover 

contribution, shows the code SC.

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

qualified disaster distribution, or a qualified birth or adoption distribution. See Pub.

590-A for reporting repayments.

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

code DD for repayment of a qualified disaster distribution, or code BA for repayment 

of a qualified birth or adoption distribution.

Box 15a. Shows the FMV of the investments in the IRA that are specified in the 

categories identified in box 15b.

Box 15b. The following codes show the type(s) of investments held in your account for 

which the FMV is required to be reported in box 15a.

A—Stock or other ownership interest in a corporation that is not readily tradable on an 

established securities market.

B—Short- or long-term debt obligation that is not traded on an established securities market. 

C—Ownership interest in a limited liability company or similar entity (unless the 

interest is traded on an established securities market). 

D—Real estate.

E—Ownership interest in a partnership, trust, or similar entity (unless the interest is 

traded on an established securities market). 

F—Option contract or similar product that is not offered for trade on an established 

option exchange.

G—Other asset that does not have a readily available FMV.

H—More than two types of assets (listed in A through G) are held in this IRA.
 

Form 5498

2021

IRA 

Contribution 

Information

Copy C

For 

Trustee or Issuer

Department of the Treasury - Internal Revenue Service

OMB No. 1545-0747

For Privacy Act 

and Paperwork 

Reduction Act 

Notice, see the 

2021 General

Instructions for

Certain

Information

Returns.

VOID CORRECTED

TRUSTEE’S or ISSUER’S name, street address, city or town, state or 

province, country, and ZIP or foreign postal code

TRUSTEE’S or ISSUER’S TIN PARTICIPANT’S TIN

PARTICIPANT’S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

Account number (see instructions)

1 IRA contributions (other 

than amounts in boxes

2–4, 8–10, 13a, and 14a)

$

2 Rollover contributions

$

3 Roth IRA conversion 

amount

$

4 Recharacterized 

contributions

$

5 FMV of account

$

6 Life insurance cost included in 

box 1

$

7 IRA SEP SIMPLE Roth IRA

8 SEP contributions

$

9 SIMPLE contributions

$

10 Roth IRA contributions

$

11 Check if RMD for 2022

12a RMD date 12b RMD amount

$

13a Postponed/late contrib.

$

13b Year 13c Code

14a Repayments

$

14b Code

15a FMV of certain specified 

assets

$

15b Code(s)

Form 5498 www.irs.gov/Form5498
Instructions for Trustee or Issuer

To complete Form 5498, use:

• The 2021 General Instructions for Certain 

Information Returns, and 

• The 2021 Instructions for Forms 1099-R and 

5498.

To order these instructions and additional forms, 

go to www.irs.gov/Form5498.

Caution: Because paper forms are scanned during 

processing, you cannot file Forms 1096, 1097, 

1098, 1099, 3921, or 5498 that you print from the 

IRS website.

Due dates. Furnish Copy B of this form to the

participant by May 31, 2022, but furnish FMV 

information and RMD, if applicable, by January 31, 

2022.

File Copy A of this form with the IRS by May 31, 

2022. If you file electronically, you must have 

software that generates a file according to the 

specifications in Pub. 1220. The IRS does not 

provide a fill-in form option for Copy A.

Need help? If you have questions about reporting

on Form 5498, call the information reporting

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

304-263-8700 (not toll free). Persons with a 

hearing or speech disability with access to TTY/

TDD equipment can call 304-579-4827 (not toll 

free).