Form 5498-ESA Form 5498-ESA 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 may be imposed for filing forms that can’t be scanned. See part O in the
current General Instructions for Certain Information Returns for more information about
penalties.
To order official IRS forms, call 1-800-TAX-FORM (1-800-829-3676) or Order
Information Returns and Employer Returns Online, and we’ll mail you the scannable
forms and other products.
See IRS Publications 1141, 1167, 1179 and other IRS resources for information about
printing these tax forms.

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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

2012

Coverdell ESA
Contribution
Information

Form 5498-ESA

Copy A
For
Internal Revenue
Service Center

BENEFICIARY'S name

File with Form 1096.
Street address (including apt. no.)

For Privacy Act and
Paperwork Reduction
Act Notice, see the
2012 General
Instructions for
Certain Information
Returns.

City, state, and ZIP code
Account number (see instructions)
Form 5498-ESA

Cat. No. 34011J

Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page — 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

2012

Coverdell ESA
Contribution
Information

Form 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, 2013. Form 5498ESA reports contributions and rollover contributions
made for you for 2012. For more information about
Coverdell ESAs, see Pub. 970, Tax Benefits for
Education.
Beneficiary's identification number. For your
protection, this form may show only the last four digits
of your social security number (SSN), individual
taxpayer identification number (ITIN), or adoption
taxpayer identification number (ATIN). However, the
issuer has reported your complete identification number
to the IRS and, where applicable, to state and/or local
governments.
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
2012 and through April 15, 2013, on your behalf. Do not
deduct these amounts on your income tax return.
If the total contributions made to all your Coverdell
ESAs for 2012 exceeded $2,000, you must withdraw the
excess, plus earnings, by May 31, 2013, 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 2012. 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
BENEFICIARY'S name

Street address (including apt. no.)
City, state, and ZIP code
Account number (see instructions)
Form 5498-ESA

2012

Coverdell ESA
Contribution
Information

Form 5498-ESA

Copy C
For Trustee
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2012 General
Instructions for
Certain
Information
Returns.
Department of the Treasury - Internal Revenue Service

Instructions for Trustee or Issuer

General and specific form instructions are provided as
separate products. The products you should use to
complete Form 5498-ESA are the 2012 General
Instructions for Certain Information Returns and the
2012 Instructions for Form 5498-ESA. To order these
instructions and additional forms, visit 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, 1097, 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, 2013.

File Copy A of this form with the IRS by May 31, 2013.
To file electronically, you must have software that
generates a file according to the specifications in Pub.
1220, Specifications for Filing Forms 1097, 1098, 1099,
3921, 3922, 5498, 8935, 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
304-579-4827 (not toll free). The hours of operation are
Monday through Friday from 8:30 a.m. to 4:30 p.m.,
Eastern time.