5498-QA ABLE Account Contribution Information

Tax Forms & Publications
Work Request Notification (WRN)/Circulation
Product

Form 5498-QA

Title

ABLE Account Contributions Information

Tax year 2015
This is the Second
work requests.

Processing year 2016
circulation of this product for your review and comments. This circulation can be used to support any necessary

Authority for changes that may impact a Unified Work Request (UWR) (For changes, see Description of Major Changes below)
P.L. 113-295, Division B

Signature of Approving Official

Circulation signature date
Digitally signed by 8GSNB
DN: cn=8GSNB, [email protected]
Date: 2015.04.10 15:59:12 -04'00'

8GSNB

04/10/2015

Description of Major Changes (A description of changes to a form's instructions that may impact a UWR is also included, as applicable)
This is the 2nd WRN/circulation for Form 5498-QA for TY15PY16.
--Box 4 has been unshaded and "Fair market value" has been added as a title. Reporting fair market value will ensure annual reporting to ensure that
a qualified individual has only 1 ABLE account. IRC 529A(g)(1)
--Box 7, Code, has been created to provide for reporting by disability category to gather information for aggregate reports that can be collected easily
and with minimal burden on trustees. IRC 529A(d)(2)
The first WRN, circulated on March 26, 2015, contained the changes below.
--This is a new form, Form 5498-QA, ABLE Account Contributions Information. P.L. 113-295, ABLE Act of 2014 allows individuals and families
to set money aside in this special account for the purpose of supporting individuals with disabilities to maintain health, independence, and quality of
life, without impacting eligibility for other social service financial assistance programs such as Medicaid.

Comments: Comments are due 30 days after the date this circulation is signed and issued, unless a different date is specified here:
.
Comments should be sent via email to both the Tax Law Specialist and Reviewer listed below. We will accept comments after the due date, but may not
be able to consider any comments (timely or not) for this revision if implementing the comments would require a late UWR. If we need to make
significant changes based on comments or other new information received, we normally will issue a subsequent circulation of this product; otherwise,
these changes are final unless indicated otherwise in the Description of Major Changes.

Name of Tax Law Specialist Janice Y. Martin

Name of Reviewer Melody G. DeVoe

Email address [email protected]

Email address [email protected]

Form 14216 (Rev. 6-2014)

Catalog Number 57440M

publish.no.irs.gov

Department of the Treasury - Internal Revenue Service

XXXX

Version A, Cycle 4
Dimensions: 7.3" x 3.75"; .5" head margin to top rule

VOID

CORRECTED

TRUSTEE’S or ISSUER'S name, street address, city or town, state or
province, country, and ZIP or foreign postal code

1 ABLE contributions

OMB No. 1545-XXXX

2 Rollover contributions

TRUSTEE’S/ISSUER’S federal identification no. BENEFICIARY'S social security number

3 Cumulative contributions

ABLE Account
Contribution
Information

2015

$

$

Fair market value
$

Form 5498-QA

unshade box

Copy A

4

$
BENEFICIARY'S name

5 Check if account opened
in 2015

6 Date individual certified
ABLE account qualified

For
Internal Revenue
Service Center
File with Form 1096.

Street address (including apt. no.)

For Privacy Act and
Paperwork Reduction
Act Notice, see the
2015 General
Instructions for
Certain Information
Returns.

City or town, state or province, country, and ZIP or foreign postal code

Account number (see instructions)
Form 5498-QA

Cat. No. 67556T

www.irs.gov/form5498qa

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
7 Code
unshade new box 7

add line

INTERAL USE ONLY
DRAFT AS OF
March 16, 2015

Version A, Cycle 4
Dimensions: 7.3" x 3.75"; .5" head margin to top rule

CORRECTED
TRUSTEE’S or ISSUER'S name, street address, city or town, state or
province, country, and ZIP or foreign postal code

1 ABLE contributions

ABLE Account
Contribution
Information

2015

$
2 Rollover contributions

unshade box

Form 5498-QA

$
TRUSTEE’S/ISSUER’S federal identification no. BENEFICIARY'S social security number

Fair market value
$

OMB No. 1545-XXXX

3 Cumulative contributions

Copy B

4

$
BENEFICIARY'S name

5 If checked, account was
opened in 2015

Street address (including apt. no.)

6 Date individual certified
ABLE account qualified

For Beneficiary
This information
is being furnished
to the Internal
Revenue Service.

City or town, state or province, country, and ZIP or foreign postal code

Account number (see instructions)
Form 5498-QA

(keep for your records)

7 Code

www.irs.gov/form5498qa

Department of the Treasury - Internal Revenue Service

add line
unshade entire area

INTERAL USE ONLY
DRAFT AS OF
March 16, 2015

March 15

Version A, Cycle 4
Dimensions: 7.3" x 3.75"; .5" head margin to top rule

Instructions for Beneficiary
The information on Form 5498-QA is furnished to you by
the trustee or issuer of your Achieving a Better Life
Experience (ABLE) savings account by May 2, 2016. Form
5498-QA reports contributions and rollover contributions
made for you for 2015.
Beneficiary's taxpayer 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.
Account number. May show an account or other unique
number the trustee/issuer assigned to distinguish your
account.
Box 1. Shows ABLE account contributions made in 2015
on your behalf. Do not deduct these amounts on your
income tax return.
If the total contributions made to your ABLE account for
2015 exceeded $14,000, you must withdraw the excess,
plus earnings, by the date your tax return is due (including

extensions), or you may owe a penalty. You must keep
track of your ABLE account basis (contributions and
distributions).
Box 2. Shows any rollover (including a direct rollover) you
made in 2015. Generally, any amount rolled over from one
ABLE account to another ABLE account for the benefit of
the named beneficiary or a member of the beneficiary's
family who is described in section 152(d)(2)(B) is not
taxable.
Box 3. Shows the cumulative contributions made to the
ABLE account.
Box 4. Reserved.
Box 5. The ABLE account was opened in 2015 if the box is
checked.
Box 6. Shows the date the individual ABLE account was
certified.
Future developments. For the latest information about
developments related to Form 5498-QA and its
instructions, such as legislation enacted after they were
published, go to www.irs.gov/form5498qa.

Shows the fair market value of the
ABLE account as of December 31,
2015.
Box 7. Reserved for code descriptions

INTERAL USE ONLY
DRAFT AS OF
March 16, 2015

Version A, Cycle 4
Dimensions: 7.3" x 3.75"; .5" head margin to top rule

VOID

CORRECTED

TRUSTEE’S or ISSUER'S name, street address, city or town, state or
province, country, and ZIP or foreign postal code

1 ABLE contributions

OMB No. 1545-XXXX

2 Rollover contributions

TRUSTEE’S/ISSUER’S federal identification no. BENEFICIARY'S social security number

Form 5498-QA

3 Cumulative contributions

ABLE Account
Contribution
Information

2015

$

$

Fair market value
$

unshade box

Copy C

4

$
BENEFICIARY'S name

5 Check if account opened
in 2015

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

Account number (see instructions)
Form 5498-QA

www.irs.gov/form5498qa

6 Date individual certified
ABLE account qualified

For Trustee
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2015 General
Instructions for
Certain
Information
Returns.

Department of the Treasury - Internal Revenue Service

7 Code

add line

unshade entire area

INTERAL USE ONLY
DRAFT AS OF
March 16, 2015

Version A, Cycle 4
Dimensions: 7.3" x 3.75"; .5" head margin to top rule

Instructions for Trustee or Issuer
To complete Form 5498-QA, use:
• the 2015 General Instructions for Certain Information
Returns, and
• the 2015 Instructions for Form 5498-QA.
To order these instructions and additional forms, go
to www.irs.gov/form5498qa or call 1-800-TAX-FORM
(1-800-829-3676).
Caution. Because paper forms are scanned during
processing, you cannot file Forms 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 March 15, 2016.

File Copy A of this form with the IRS by May 31, 2016.
Need help? If you have questions about reporting on
Form 5498-QA, call the information reporting customer
service site toll free at 1-866-455-7438 or 304-263-8700
(not toll free). Persons with a hearing or speech
disability with access to TTY/TDD equipment can call
304-579-4827 (not toll free).

INTERAL USE ONLY
DRAFT AS OF
March 16, 2015