Trustee's or Issuer's name, address, ZIP code, and Federal identifying no.

1 Regular IRA, SEP, or DEC con:
tributions

2 Rollover IRA, SEP, or DEC con:
tributions

OMB No, 1545-0747

1984

Individual
Retirement
Arrangement
Information

PARTICIPANT'S name, address, and ZIP code

security

Participant's so
number

For Paperwork Reduction
Act Notice and instruc-
tions for completing this
form, see Instructions for
Form 1096.

Copy C

For Trustee
or Issuer

Form 5498

Department of the Treasury—Internal Revenue Service

Trustee's or Issuer's name, address, ZIP code, and Federal identifying no,

1 Regular IRA, SEP, or DEC con:
tributions

2 Rollover IRA, SEP, or DEC con:
tributions

OMB No. 1545-0747

1984

Individual

Retirement
Arrangement

Information

PARTICIPANT'S name, address, and ZIP code

Participant's social security
number

For Paperwork Reduction
Act Notice and instruc-
tions for completing this
form, see Instructions for
Form 1096.

Copy C
For Trustee

or Issuer

Form 5498

Department of the Treasury —Internal Revenue Service

Trustee's or Issuer's name, address, ZIP code, and Federal identifying no,

1 Regular IRA. SEP. or DEC con
tributions

2 Rollover IRA, SEP, or DEC con.
tributions.

OMB No. 1545-0747

1984

Individual
Retirement
Arrangement

Information

PARTICIPANT'S name, address, and ZIP code

Participant's social security
number

For Paperwork Reduction
Act Notice and instruc-
tions for completing this
form, see Instructions for
Form 1096

Copy C

For Trustee

or Issuer

Form 5498

Department of the Treasury — Internal Revenue Service


Instructions to Participant

The information in Boxes 1 and 2 has been submitted to
the Internal Revenue Service by the trustee or issuer of
your Individual Retirement Arrangement (IRA) or Simplified
Employee Pension (SEP) to report regular or rollover con-
tributions made to your IRA or SEP. The amount may also
represent information submitted by your employer on
deductible employee contributions (DECs) made by you to
the employer's pension plan.

The amount in Box 1 represents the contributions to a plan
during 1984, even though you may have designated some
or all of the payments for 1983. The amount in Box 2
represents any rollover contributions made or arranged by
you (other than certain direct transfers between trustees)
to the IRA, SEP or DEC during 1984.

Instructions to Participant

The information in Boxes 1 and 2 has been submitted to
the Internal Revenue Service by the trustee or issuer of
your Individual Retirement Arrangement (IRA) or Simplified
Employee Pension (SEP) to report regular or rollover con-
tributions made to your IRA or SEP. The amount may also
represent information submitted by your employer on
deductible employee contributions (DECs) made by you to
the employer's pension plan.

The amount in Box 1 represents the contributions to a plan
during 1984, even though you may have designated some
or all of the payments for 1983. The amount in Box 2
represents any rollover contributions made or arranged by
you (other than certain direct transfers between trustees)
to the IRA, SEP or DEC during 1984

Instructions to Participant

The information in Boxes 1 and 2 has been submitted to
the Internal Revenue Service by the trustee or issuer of
your Individual Retirement Arrangement (IRA) or Simplified
Employee Pension (SEP) to report regular or rollover con-
tributions made to your IRA or SEP. The amount may also
represent information submitted by your employer on
deductible employee contributions (DECs) made by you to
the employer's pension plan.

The amount in Box 1 represents the contributions to a plan
during 1984, even though you may have designated some
or all of the payments for 1983. The amount in Box 2
represents any rollover contributions made or arranged by
you (other than certain direct transfers between trustees)
to the IRA, SEP or DEC during 1984.

Do not deduct on your income tax return contributions in-
cluded in Box 1 that you made during 1984 put designated
for 1983 and deducted on your 1983 Form 1040. Also, do
not deduct any rollover contributions shown in Box 2. See
the 1984 Form 1040 instructions for information on how to
figure your deduction for contributions to an IRA, SEP or
DEC.

The trustee or issuer of the plan may use the other boxes on
the form to give you more information about your IRA or
SEP.

You are not required to attach a copy of Form 5498 to your
income tax return.

3X U.S, GOVERNMENT PRINTING OFFICE: 1983-390-259 El. 11-1897126

Do not deduct on your income tax return contributions in-
cluded in Box 1 that you made during 1984 but designated
for 1983 and deducted on your 1983 Form 1040. Also, do
not deduct any rollover contributions shown in Box 2. See
the 1984 Form 1040 instructions for information on how to
figure your deduction for contributions to an IRA, SEP or
DEC.

The trustee or issuer of the plan may use the other boxes on
the form to give you more information about your IRA or
SEP.

You are not required to attach a copy of Form 5498 to your
income tax return

‘YY U.S, GOVERNMENT PRINTING OFFICE: 1983-390-259 El, 11-1897126

Do not deduct on your income tax return contributions in-
cluded in Box 1 that you made during 1984 but designated
for 1983 and deducted on your 1983 Form 1040. Also, do
not deduct any rollover contributions shown in Box 2. See
the 1984 Form 1040 instructions for information on how to
figure your deduction for contributions to an IRA, SEP or
DEC.

The trustee or issuer of the plan may use the other boxes on
the form to give you more information about your IRA or
SEP.

You are not required to attach a copy of Form 5498 to your
income tax return.

3X U.S. GOVERNMENT PRINTING OFFICE: 1983-390-259 E.l, 11-1897126


OO 2aea 0 voip

For Official Use Only

Type or machine print Trustee's or Issuer's name

Street address

City, State, and ZIP code

Federal identifying number

‘tributions

11 Regular IRA, SEP, or DEC con-

2 Rollover IRA, SEP, or DEC con-
tributions

OMB No. 1545 0747

1984

Individual
Retirement
Arrangement
Information

Type or machine print PARTICIPANT'S name, (first, middle,
last)

Street address

City, State, and ZIP code

Participant's social security
number

For Paperwork Reduction
Act Notice and instruc-
tions for completing this
form, see Instructions for
Form 1096.

Copy A
For Internal Revenue
Service Center

Form 5498

O  7a7a-~— 1) voip

Do NOT Cut or Separate Forms on This Page

For Official Use Only

Department of the Treasury—Internal Revenue Service

Type or machine print Trustee's or Issuer's name

tributions

1 Regular IRA, SEP, or DEC con-

2 Rollover IRA, SEP, or DEC con-
tnbutions

OMB No. 1545-0747

1984

last)

Street address

City, State, and ZIP code

Street address
Individual
City, State, and ZIP code Retirement
Arrangement
Federal identifying number Information
Type or machine print PARTICIPANT'S name, (first, middle, Participant's socal security For Paperwork Reduction

Act Notice and instruc-
tions for completing this
form, see Instructions for
Form 1096.

Copy A
For Internal Revenue
Service Center

Form 5498

O 2a Oj voip

Do NOT Cut or Separate Forms on This Page

For Official Use Only

Department of the Treasury—Internal Revenue Service

Type or machine print Trustee's or Issuer's name

1 Regular IRA, SEP, or DEC con-
tributions

2 Rollover IRA, SEP, or DEC con-
tributions

OMB No. 1545-0747

1984

last)

Street address

City, State, and ZIP code

Street address
Individual
City, State, and ZIP code Retirement
Arrangement
Federal identifying number Information
Type or machine print PARTICIPANT'S name, (first, middle, | Participant's social security For Paperwork Reduction

Act Notice and instruc-
tions for completing this
form, see Instructions for
Form 1096.

Copy A
For Internal Revenue
Service Center

Form 5498

Department of the Treasury—Internal Revenue Service




Trustee's or Issuer's name, address, ZIP code, and Federal entitying no.

11 Regular IRA, SEP, or DEC con
tributions,

2 Rollover IRA, SEP, or DEC con:
tributions

OMB No. 1545-0747

1984

Individual
Retirement
Arrangement
Information

PARTICIPANT'S name, address, and ZIP code.

Participant's social security
number

This information is
being furnished to
the Internal
Revenue Service.

CopyB
For Recipient's
Records

Form 5498

Department of the Treasury—Internal Revenue Service

Trustee's or Issuer's name, address, ZIP code, and Federal identifying no,

1 Regular IRA, SEP, or DEC con:
tributions

2 Rollover IRA, SEP. or DEC con:
tributions

OMB No. 1545-0747

1984

Individual
Retirement
Arrangement
Information

PARTICIPANT'S name, address, and ZIP code.

Participant's social security
number

This information is
being furnished to
the Internal
Revenue Service.

CopyB
For Recipient's
Records

Form 5498

Department of the Treasury

Trustee's or Issuer's name, address, ZIP code, and Federal identifying no,

1 Regular IRA, SEP, or DEC con:
tnbutions

2 Rollover iRA, SEP, ar DEC con:
tributions

Internal Revenue Service

OMB No. 1545-0747

1984

Individual
Retirement
Arrangement
Information

PARTICIPANT'S name, address, and ZIP code.

Participant's social security
nut

This information is
being furnished to
the Internal
Revenue Service.

Copy B
For Recipient's
Records

Form 5498

Department of the Treasury—Internal Revenue Service