Form 5498-QA

2015

Cat. No. 67556T

ABLE Account 

Contribution 

Information

Copy A

For 

Internal Revenue 

Service Center

Department of the Treasury - Internal Revenue Service

File with Form 1096.

OMB No. 1545-2262

For Privacy Act and 

Paperwork Reduction 

Act Notice, see the 

2015 General

Instructions for

Certain Information

Returns.

YYYY VOID CORRECTED

ISSUER'S name, street address, city or town, state or province, country, and 

ZIP or foreign postal code

ISSUER’S federal identification no. BENEFICIARY'S social security number

BENEFICIARY'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 ABLE contributions

$

2 Rollover contributions

$

3 Cumulative contributions

$

4 Fair market value 

$

5 Check if account opened 

in 2015

6 Basis of eligibility 

7 Code

Form 5498-QA www.irs.gov/form5498qa

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

Form 5498-QA

2015

ABLE Account 

Contribution 

Information

Copy B

For Beneficiary

Department of the Treasury - Internal Revenue Service

This information 

is being furnished 

to the Internal 

Revenue Service.

OMB No. 1545-2262

CORRECTED

ISSUER'S name, street address, city or town, state or province, country, and 

ZIP or foreign postal code

ISSUER’S federal identification no. BENEFICIARY'S social security number

BENEFICIARY'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 ABLE contributions

$

2 Rollover contributions

$

3 Cumulative contributions

$

4 Fair market value 

$

5 If checked, account was 

opened in 2015

6 Basis of eligibility 

7 Code 

Form 5498-QA (keep for your records) www.irs.gov/form5498qa
Instructions for Beneficiary

The information on Form 5498-QA is furnished to you by the issuer of 

your Achieving a Better Life Experience (ABLE) savings account by 

March 15, 2016. Form 5498-QA reports contributions and rollover 

contributions made for you for 2015. For more information, see Pub. 907. 

Beneficiary's taxpayer identification number. For your protection, 

this form may show only the last four digits of your social security 

number (SSN), individual taxpayer identification number (ITIN), or 

adoption taxpayer identification number (ATIN). However, the issuer 

has reported your complete identification number to the IRS.

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

assigned to distinguish your account.

Box 1. Shows ABLE account contributions made in 2015 on your 

behalf. Do not deduct these amounts on your income tax return.

If the total contributions made to your ABLE account for 2015 

exceeded $14,000, the excess contributions, plus the earnings on 

them, must be returned by the date your tax return is due (including 

extensions), or you may owe a penalty. Check with your ABLE 

program to verify that excess contributions and earnings are returned. 

You must keep track of your ABLE account basis (contributions and 

distributions). 

Box 2. Shows any rollover (including a direct rollover) you made in 

2015. Generally, any amount rolled over from one ABLE account to 

another ABLE account for the benefit of the named beneficiary or a 

member of the beneficiary's family who is described in section 152(d)

(2)(B) is not taxable.

Box 3. Shows the cumulative contributions made to the ABLE 

account.

Box 4. Shows the FMV of the ABLE account as of the end of the year.

Box 5. The ABLE account was opened in 2015 if the box is checked.

Box 6. These codes show the basis for your ABLE account eligibility. 

A—eligibility established under 529A(e)(1)(A), SSDI, Title II SSA. 

B—eligibility established under 529A(e)(1)(A), SSI, Title XVI SSA. 

C—eligibility established by disability certification under section 

529A(e)(1)(B). 

Box 7. These codes show the type of disability for which you are 

receiving ABLE account qualifying benefits. 1—developmental 

disorders (including autism); 2—intellectual disability; 3—psychiatric 

disorders; 4—nervous disorders (including blindness and deafness); 

5—congenital anomalies (including Downs syndrome); 6—respiratory 

disorders; 7—other.

Future developments. For the latest information about developments 

related to Form 5498-QA and its instructions, such as legislation 

enacted after they were published, go to www.irs.gov/form5498qa.
 

Form 5498-QA

2015

ABLE Account 

Contribution 

Information

Copy C

For Issuer

Department of the Treasury - Internal Revenue Service

OMB No. 1545-2262

For Privacy Act 

and Paperwork 

Reduction Act 

Notice, see the 

2015 General

Instructions for

Certain 

Information

Returns.

VOID CORRECTED

ISSUER'S name, street address, city or town, state or province, country, and 

ZIP or foreign postal code

ISSUER’S federal identification no. BENEFICIARY'S social security number

BENEFICIARY'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 ABLE contributions

$

2 Rollover contributions

$

3 Cumulative contributions

$

4 Fair market value 

$

5 Check if account opened 

in 2015

6 Basis of eligibility 

7 Code 

Form 5498-QA www.irs.gov/form5498qa
Instructions for Issuer

To complete Form 5498-QA, use: 

• the 2015 General Instructions for Certain Information 

Returns, and 

• the 2015 Instructions for Form 5498-QA.

To order these instructions and additional forms, go 

to www.irs.gov/form5498qa.

Caution: Because paper forms are scanned during

processing, you cannot file Forms 1096, 1097, 1098,

1099, 3921, 3922, or 5498 that you download and print

from the IRS website.

Due dates. Furnish Copy B of this form to the

beneficiary (participant) by March 15, 2016.

File Copy A of this form with the IRS by May 31, 2016. 

Need help? If you have questions about reporting on

Form 5498-QA, call the information reporting customer

service site toll free at 1-866-455-7438 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).