VOID CORRECTED

IRA contributions (other

than amounts in boxes 2,

3, 4, and 8–11)

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 5 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, see the

2001 General

Instructions for

Forms 1099, 1098,

5498, and W-2G.

Form 5498

OMB No. 1545-0747

7 IRA SEP SIMPLE

8 SEP contributions 9 SIMPLE contributions

$ $

10 Roth IRA contributions 11 Ed IRA contributions

$ $

Roth IRA Ed IRA

Life insurance cost

included in box 1

6

$

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

2001

4 Recharacterized contributions

$
CORRECTED (if checked)

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

TRUSTEE’S or ISSUER’S Federal identification no. PARTICIPANT’S social security number

PARTICIPANT’S name

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

Contribution

Information

This information

is being

furnished to

the Internal

Revenue

Service.

IRA contributions (other

than amounts in boxes 2,

3, 4, and 8–11)

1

$

2 Rollover contributions

$

3 Roth conversion amount

$

5 Fair market value of account

$

Form 5498

OMB No. 1545-0747

7 IRA SEP SIMPLE

8 SEP contributions 9 SIMPLE contributions

$ $

10 Roth IRA contributions 11 Ed IRA contributions

$ $

Roth IRA Ed IRA

Life insurance cost

included in box 1

6

$

2001

4 Recharacterized contributions

$
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 6. 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 5. Shows the fair market value of your account at year end.

Box 1. Shows traditional IRA contributions for 2001 you made in 2001

and through April 15, 2002. 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 2–4 and 8–11.

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

you made in 2001. It does not show any amounts you converted from

your traditional IRA, SEP IRA, or SIMPLE IRA 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 or SEP IRA and you did not roll over

the total distribution, use Form 8606, Nondeductible IRAs, to figure the

taxable amount. If property was rolled over, see Pub. 590.

Box 7. May show the kind of IRA reported on this Form 5498.

Box 8. Shows SEP contributions made in 2001, including contributions

made in 2001 for 2000, but not including contributions made in 2002 for

2001. 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 9. Shows SIMPLE contributions made in 2001. 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 11. Shows education IRA (Ed IRA) contributions made in 2001 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 15, or you

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

(contributions and distributions). See Pub. 590.

Box 10. Shows Roth IRA contributions you made in 2001 and through

April 15, 2002. Do not deduct on your income tax return.

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

IRA to a Roth IRA in 2001. Use Form 8606 to figure the taxable amount. Instructions to Participant

Reminder: If you converted from a traditional IRA, simplified employee

pension (SEP) IRA, or savings incentive match plan for employees

(SIMPLE) IRA 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 2001. See your Form 1040

instructions.

Box 4. Shows amounts recharacterized from transferring any part of the

contribution (plus earnings) from one type of IRA to another. See Pub. 590.
VOID CORRECTED

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

TRUSTEE’S or ISSUER’S Federal identification no. PARTICIPANT’S social security number

PARTICIPANT’S name

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, see the

2001 General

Instructions for

Forms 1099,

1098, 5498,

and W-2G.

Copy C

IRA

Contribution

Information

IRA contributions (other

than amounts in boxes 2,

3, 4, and 8–11)

1

$

2 Rollover contributions

$

3 Roth conversion amount

$

5 Fair market value of account

$

Form 5498

OMB No. 1545-0747

7 IRA SEP SIMPLE

8 SEP contributions 9 SIMPLE contributions

$ $

10 Roth IRA contributions 11 Ed IRA contributions

$ $

Roth IRA Ed IRA

Life insurance cost

included in box 1

6

$

2001

4 Recharacterized contributions

$
Trustees and Issuers, Please Note—

To help make it easier for you to get only the

information you need to complete the Forms

1099, 1098, 5498, and W-2G you file, we provide

general and specific form instructions as separate

products. The products you should use for 2001

are the General Instructions for Forms 1099,

1098, 5498, and W-2G, which contain general

information concerning Form 5498 and forms in

the 1099 series, and the separate specific

instructions for each information return you file.

Specific information needed to complete this form

is given in the 2001 Instructions for Forms

1099-R and 5498. You can order these

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.gov.

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

Copy B of this form to the participant by January

31, 2002. For all other types of accounts, furnish

Copy B by May 31, 2002, but furnish fair market

value information by January 31, 2002.

File Copy A of this form with the IRS by May

31, 2002.

Caution: Because the IRS processes paper forms

by machine (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.