Form 5498-QA

2016

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 

2016 General

Instructions for

Certain Information

Returns.

2A2A 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 2016

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

2016

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 2016

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. Form 

5498-QA reports contributions, rollovers, and program-to-program 

transfers to this ABLE account for 2016. 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 the amount of contributions made to this ABLE account 

in 2016. Do not deduct these amounts on your income tax return.

If the total contributions made to your ABLE account for 2016 

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 the amount of any rollover or program-to-program transfer 

made to this ABLE account in 2016. Generally, any amount rolled over 

from one ABLE account to another ABLE account for the benefit of 

the named beneficiary or of an eligible individual who is a member of 

the beneficiary's family who is described in section 152(d)(2)(B) is not 

taxable.

Box 3. May show the cumulative amount contributed since the 

establishment of the ABLE account (or of an ABLE account of the 

same designated beneficiary that was rolled over, or directly 

transferred (in a program-to-program transfer), to the current 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 2016 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

2016

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 

2016 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 2016

6 Basis of eligibility 

7 Code 

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

To complete Form 5498-QA, use: 

• the 2016 General Instructions for Certain Information 

Returns, and 

• the 2016 Instructions for Form 5498-QA.

To order these instructions and additional forms, go 

to www.irs.gov/form5498qa.

Due dates. Furnish Copy B of this form to the

beneficiary (participant) by March 15, 2017.

File Copy A of this form with the IRS by May 31, 2017. 

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).