VOID CORRECTED

IRA contributions (other

than amounts in boxes 2,

3, and 7–10)

TRUSTEE’S or ISSUER’S name, street address, city, state, and ZIP code 1

IRA

Contribution

Information

$

2 Rollover contributions

$

TRUSTEE’S or ISSUER’S Federal identification no. PARTICIPANT’S social security number 3 Roth conversion amount

$

PARTICIPANT’S name 4 Fair market value of account

$

Street address (including apt. no.)

City, state, and ZIP code

Account number (optional)

Form 5498 Department of the Treasury - Internal Revenue Service

2828

Cat. No. 50010C

Copy A

For

Internal Revenue

Service Center

File with Form 1096.

For Privacy Act and

Paperwork Reduction

Act Notice and

instructions for

completing this

form, see the

1999 Instructions for

Forms 1099, 1098,

5498, and W-2G.

Form 5498

OMB No. 1545-0747

6 IRA SEP SIMPLE

7 SEP contributions 8 SIMPLE contributions

$ $

9 Roth IRA contributions 10 Ed IRA contributions

$ $

Roth IRA Rechar. Ed IRA

Life insurance cost

included in box 1

5

$

1999

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

CORRECTED (if checked)

TRUSTEE’S or ISSUER’S name, street address, city, state, and ZIP code 1

$

2 Rollover contributions

$

TRUSTEE’S or ISSUER’S Federal identification no. PARTICIPANT’S social security number 3 Roth conversion amount

$

PARTICIPANT’S name 4 Fair market value of account

$

Street address (including apt. no.)

City, state, and ZIP code

Account number (optional)

Form 5498 Department of the Treasury - Internal Revenue Service

For

Participant

Copy B

(Keep for your records.)

IRA contributions (other

than amounts in boxes 2,

3, and 7–10)

Form 5498

OMB No. 1545-0747

IRA

Contribution

Information

6

7 SEP contributions 8 SIMPLE contributions

$ $

9 Roth IRA contributions 10 Ed IRA contributions

$ $

IRA SEP SIMPLE

This information

is being

furnished to

the Internal

Revenue

Service.

Life insurance cost

included in box 1

5

$

Roth IRA Rechar. Ed IRA

1999
The information on Form 5498 is submitted to the Internal Revenue

Service by the trustee or issuer of your individual retirement arrangement

(IRA) to report contributions and the fair market value of the account. For

information about IRAs, see Pub. 590, Individual Retirement

Arrangements (IRAs), and Pub. 560, Retirement Plans for Small Business.

Box 5. For endowment contracts only, shows 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 4. Shows the fair market value of your account at year end.

Box 1. Shows traditional IRA contributions for 1999 you made in 1999

and through April 17, 2000. These contributions may be deductible on

your Form 1040 or 1040A. 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, 3, and 7-10.

Box 2. Shows any rollover, including a direct rollover to a traditional IRA,

you made in 1999. It also shows amounts recharacterized from one type

of IRA to another. However, it does not show any amounts you converted

from your traditional IRA, simplified employee pension (SEP), or savings

incentive match plan for employees (SIMPLE) to a Roth IRA. They are

shown in box 3. See the Form 1040 or 1040A instructions for information

on how to report rollovers. If you have ever made any nondeductible

contributions to your traditional IRA, SEP, or SIMPLE 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.

Box 6. May show the kind of IRA reported on this Form 5498. If

“Rechar.” is checked, the contribution is a recharacterization of a prior

contribution from one type of IRA to another.

Box 7. Shows simplified employee pension (SEP) contributions made in

1999. 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 8. Shows the savings incentive match plan for employees (SIMPLE)

contributions made in 1999. 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 education IRA (Ed IRA) contributions made in 1999 on

your behalf. Do not deduct on your income tax return. If the total of all

contributions made to all your Ed IRAs this year exceeded $500, you

should withdraw the excess, plus earnings, generally by April 17, or you

may owe a penalty. You must keep track of your Ed IRA basis

(contributions and distributions). See Pub. 590.

Box 9. Shows Roth IRA contributions you made in 1999 and through

April 17, 2000. Do not deduct on your income tax return.

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

SIMPLE to a Roth IRA in 1999. Use Form 8606 to figure the taxable

amount.

Instructions to Participant

Reminder: If you converted from a traditional IRA, SEP, or SIMPLE to a

Roth IRA in 1998 and you elected to spread the taxable income over 4

years, you must include one-fourth of the taxable amount converted in

your income in 1999. See Form 8606, Nondeductible IRAs.
VOID CORRECTED

TRUSTEE’S or ISSUER’S name, street address, city, state, and ZIP code 1

$

2 Rollover contributions

$

TRUSTEE’S or ISSUER’S Federal identification no. PARTICIPANT’S social security number 3 Roth conversion amount

$

PARTICIPANT’S name 4 Fair market value of account

$

Street address (including apt. no.)

City, state, and ZIP code

Account number (optional)

Form 5498 Department of the Treasury - Internal Revenue Service

For

Trustee or Issuer

For Privacy Act and

Paperwork Reduction

Act Notice and

instructions for

completing this

form, see the

1999 Instructions for

Forms 1099, 1098,

5498, and W-2G.

Copy C

IRA contributions (other

than amounts in boxes 2,

3, and 7–10)

Form 5498

OMB No. 1545-0747

IRA

Contribution

Information

6

7 SEP contributions 8 SIMPLE contributions

$ $

9 Roth IRA contributions 10 Ed IRA contributions

$ $

IRA SEP SIMPLE

$

Life insurance cost

included in box 1

5

Roth IRA Rechar. Ed IRA

1999
Trustees and Issuers, Please Note—

Specific information needed to complete this

form and forms in the 1099 series is given in

the 1999 Instructions for Forms 1099, 1098,

5498, and W-2G. You can order those

instructions and additional forms by calling

1-800-TAX-FORM (1-800-829-3676). You can

also get forms and instructions from the IRS’s

Internet Web Site at www.irs.ustreas.gov.

Due dates. For an education IRA (Ed IRA),

furnish Copy B of this form to the participant

by January 31, 2000. For all other types of

accounts, furnish Copy B by May 31, 2000,

but furnish fair market value information by

January 31, 2000.

File Copy A of this form with the IRS by

May 31, 2000.

Caution: Because the IRS processes paper

forms by machines (optical character

recognition equipment), you cannot file with

the IRS Forms 1096, 1098, 1099, or 5498

that you print from the IRS’s Internet Web

Site.