VOID CORRECTED

Regular IRA contributions

made in 1995 and 1996

for 1995

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

Individual

Retirement

Arrangement

Information

$

2 Rollover IRA contributions

$

TRUSTEE’S or ISSUER’S Federal identification no. PARTICIPANT’S social security number 3 Life insurance cost included in box 1

$

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

Do NOT Cut or Separate Forms on This Page

Cat. No. 50010C

Copy A

For

Internal Revenue

Service Center

File with Form 1096.

For Paperwork

Reduction Act

Notice and

instructions for

completing this form,

see Instructions for

Forms 1099, 1098,

5498, and W-2G.

Form 5498

OMB No. 1545-0747
CORRECTED (if checked)

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

Individual

Retirement

Arrangement

Information

$

2 Rollover IRA contributions

$

TRUSTEE’S or ISSUER’S Federal identification no. PARTICIPANT’S social security number 3 Life insurance cost included in box 1

$

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

The information

in boxes 1, 2, 3,

and 4 is being

furnished to the

Internal Revenue

Service.

(Keep for your records.)

Regular IRA contributions

made in 1995 and 1996

for 1995

Form 5498

OMB No. 1545-0747
Instructions to Participant

The information in boxes 1, 2, 3, and 4 is submitted to the

Internal Revenue Service by the trustee or issuer of your

individual retirement arrangement (IRA) to report regular or

rollover contributions made to your IRA and the value of your

IRA or simplified employee pension (SEP) account. Box 3.—For endowment contracts only, this is the amount

allocable to the cost of life insurance. Subtract this amount

from your allowable IRA contribution included in box 1 to

compute the amount allowable for your IRA deduction.

If you or your spouse was an active participant in an

employer’s pension plan, your IRA contributions may not be

deductible. See your Form 1040 or 1040A instructions for

details. Box 4.—This is the fair market value (FMV) of your account

at the end of the year. However, if a decedent is shown as

the participant on this form, it may be the FMV at the date of

death. If a decedent’s name is shown as the participant and

the FMV shown is zero, the executor or administrator of the

decedent’s estate may request a date-of-death valuation

Box 1.—The amount shown is the contributions for 1995 from the financial institution.

made in 1995 and through April 15, 1996, to an IRA.

Box 2.—This is the amount of any rollover, including a direct

rollover, you made in 1995. You must report the total

distribution you received from your IRA on the appropriate

line of your income tax return. Subtract the part of the

distribution that was rolled over and enter the taxable

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

income tax return. Keep this form for your records. For more

information about IRAs, see Pub. 590.

The trustee or issuer of the plan may use the other boxes

on this form to give you more information about your IRA.

Caution: If you are at least 701⁄2, you must take minimum

distributions from your IRA. If you inherited this IRA, certain

minimum distribution rules apply. See Pub. 590, Individual

Retirement Arrangements (IRAs).

remainder on the appropriate line of your income tax return.

But if you have ever made any nondeductible contributions

to your IRA, use Form 8606, Nondeductible IRAs

(Contributions, Distributions, and Basis) to figure the taxable

amount. If property was rolled over, see Pub. 590.
VOID CORRECTED

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

Individual

Retirement

Arrangement

Information

$

2 Rollover IRA contributions

$

TRUSTEE’S or ISSUER’S Federal identification no. PARTICIPANT’S social security number 3 Life insurance cost included in box 1

$

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 Paperwork

Reduction Act

Notice and

instructions for

completing this

form, see

Instructions for

Forms 1099, 1098,

5498, and W-2G.

Copy C

Regular IRA contributions

made in 1995 and 1996

for 1995

Form 5498

OMB No. 1545-0747
Trustees and Issuers, Please Note—

Specific information needed to complete this form and forms

in the 1099 series is given in the 1995 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).

Furnish Copy B of this form to the participant by May 31,

1996. But furnish fair market value information by January

31, 1996.

File Copy A of this form with the IRS by May 31, 1996.

Printed on recycled paper