Coverdell ESA Contribution Information

Attention:
This form is provided for informational purposes only. Copy A appears in red, similar
to the official IRS form. Do not file copy A downloaded from this website. The official
printed version of this IRS form is scannable, but the online version of it, printed from
this website, is not. A penalty of $50 per information return may be imposed for filing
forms that cannot be scanned.

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See IRS Publications 1141, 1167, 1179 and other IRS resources for information
about printing these tax forms.

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VOID

CORRECTED
1 Coverdell ESA contributions OMB No. 1545-1815

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

$
2 Rollover contributions

$
TRUSTEE’S/ISSUER’S federal identification no.

2009
Form

Coverdell ESA
Contribution
Information

5498-ESA
Copy A

BENEFICIARY’S social security number

For
Internal Revenue
Service Center

BENEFICIARY’S name

File with Form 1096.

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2009 General
Instructions for
Forms 1099, 1098,
3921, 3922, 5498,
and W-2G.

Street address (including apt. no.)

City, state, and ZIP code

Account number (see instructions)

Form

5498-ESA

Cat. No. 34011J

Do Not Cut or Separate Forms on This Page

—

Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page

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

1 Coverdell ESA contributions OMB No. 1545-1815

$
2 Rollover contributions

$
TRUSTEE’S/ISSUER’S federal identification no.

BENEFICIARY’S social security number

2009
Form

Coverdell ESA
Contribution
Information

5498-ESA
Copy B
For Beneficiary

BENEFICIARY’S name

The information
in boxes 1 and 2
is being furnished
to the Internal
Revenue Service.

Street address (including apt. no.)

City, state, and ZIP code

Account number (see instructions)

Form

5498-ESA

(keep for your records)

Department of the Treasury - Internal Revenue Service

Instructions for Beneficiary
The information on Form 5498-ESA is furnished to you
by the trustee or issuer of your Coverdell education
savings account (ESA) by April 30, 2010. Form
5498-ESA reports contributions and rollover
contributions made for you for 2009. For more
information about Coverdell ESAs, see Pub. 970, Tax
Benefits for Education.
Account number. May show an account or other
unique number the trustee/issuer assigned to
distinguish your account.
Box 1. Shows Coverdell ESA contributions made in
2009 and through April 15, 2010, on your behalf. Do
not deduct these amounts on your income tax return.

If the total contributions made to all your Coverdell
ESAs for 2009 exceeded $2,000, you must withdraw
the excess, plus earnings, by June 1, 2010, or you
may owe a penalty. You must keep track of your
Coverdell ESA basis (contributions and distributions).
Box 2. Shows any rollover (including a direct rollover
and contribution of a military death gratuity) you made
in 2009. Generally, any amount rolled over from one
Coverdell ESA to another Coverdell ESA for the benefit
of the named beneficiary or a member of the
beneficiary’s family who is under age 30 (except for a
beneficiary with special needs) is not taxable.

VOID

CORRECTED

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

1 Coverdell ESA contributions OMB No. 1545-1815

$
2 Rollover contributions

$
TRUSTEE’S/ISSUER’S federal identification no.

BENEFICIARY’S social security number

2009
Form

Coverdell ESA
Contribution
Information

5498-ESA
Copy C
For Trustee

BENEFICIARY’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (see instructions)

Form

5498-ESA

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2009 General
Instructions for
Forms 1099,
1098, 3921, 3922,
5498, and W-2G.
Department of the Treasury - Internal Revenue Service

Instructions for Trustees or Issuers
General and specific form instructions are provided as
separate products. The products you should use to
complete Form 5498-ESA are the 2009 General
Instructions for Forms 1099, 1098, 3921, 3922, 5498,
and W-2G and the 2009 Instructions for Form
5498-ESA. To order these instructions and additional
forms, visit the IRS website at www.irs.gov or call
1-800-TAX-FORM (1-800-829-3676).
Caution: Because paper forms are scanned during
processing, you cannot file Form 1096, 1098, 1099,
3921, 3922, or 5498 that you download and print from
the IRS website.
Due dates. Furnish Copy B of this form to the
beneficiary (participant) by April 30, 2010.

File Copy A of this form with the IRS by
June 1, 2010. To file electronically, you must have
software that generates a file according to the
specifications in Pub. 1220, Specifications for Filing
Forms 1098, 1099, 3921, 3922, 5498, and W-2G
Electronically. IRS does not provide a fill-in form
option.
Need help? If you have questions about reporting on
Form 5498-ESA, call the information reporting
customer service site toll free at 1-866-455-7438 or
304-263-8700 (not toll free). For TTY/TDD equipment,
call 304-267-3367 (not toll free).