Form 5498-QA ABLE Account Contribution Information

2A2A

VOID

CORRECTED

ISSUER'S name, street address, city or town, state or province, country, and 1 ABLE contributions
ZIP or foreign postal code

OMB No. 1545-2262

2017

$
2 Rollover contributions

$

Form 5498-QA

3 Cumulative contributions

4 Fair market value

$

$

BENEFICIARY'S name

5 Check if account opened
in 2017

6 Basis of eligibility

Street address (including apt. no.)

7 Code

ISSUER’S federal identification no.

BENEFICIARY'S social security number

ABLE Account
Contribution
Information
Copy A
For
Internal Revenue
Service Center
File with Form 1096.

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

For Privacy Act and
Paperwork Reduction
Act Notice, see the
2017 General
Instructions for
Certain Information
Returns.
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
ISSUER'S name, street address, city or town, state or province, country, and 1 ABLE contributions
ZIP or foreign postal code

OMB No. 1545-2262

2017

$
2 Rollover contributions

$
ISSUER’S federal identification no.

BENEFICIARY'S social security number

BENEFICIARY'S name

Form 5498-QA

3 Cumulative contributions

4 Fair market value

$

$

5 If checked, account was
opened in 2017

6 Basis of eligibility

7 Code

Street address (including apt. no.)

ABLE Account
Contribution
Information
Copy B
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)

www.irs.gov/form5498qa

Department of the Treasury - Internal Revenue Service

Instructions for Beneficiary
The information on Form 5498-QA is furnished to you by the issuer of
your Achieving a Better Life Experience (ABLE) savings account. Form
5498-QA reports contributions, rollovers, and program-to-program
transfers to this ABLE account for 2017. For more information, see
Pub. 907.
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
issuer assigned to distinguish your account.
Box 1. Shows the amount of contributions made to this ABLE account
in 2017. Do not deduct these amounts on your income tax return.
If the total contributions made to your ABLE account for 2017
exceeded $14,000, the excess contributions, plus the earnings on
them, must be returned by the date your tax return is due (including
extensions), or you may owe a penalty. Check with your ABLE
program to verify that excess contributions and earnings are returned.
You must keep track of your ABLE account basis (contributions and
distributions).
Box 2. Shows the amount of any rollover or program-to-program transfer
made to this ABLE account in 2017. Generally, any amount rolled over

from one ABLE account to another ABLE account for the benefit of
the named beneficiary or of an eligible individual who is a member of
the beneficiary's family who is described in section 152(d)(2)(B) is not
taxable.
Box 3. May show the cumulative amount contributed since the
establishment of the ABLE account (or of an ABLE account of the
same designated beneficiary that was rolled over, or directly
transferred (in a program-to-program transfer), to the current ABLE
account).
Box 4. Shows the FMV of the ABLE account as of the end of the year.
Box 5. The ABLE account was opened in 2017 if the box is checked.
Box 6. These codes show the basis for your ABLE account eligibility.
A—eligibility established under 529A(e)(1)(A), SSDI, Title II SSA.
B—eligibility established under 529A(e)(1)(A), SSI, Title XVI SSA.
C—eligibility established by disability certification under section
529A(e)(1)(B).
Box 7. These codes show the type of disability for which you are
receiving ABLE account qualifying benefits. 1—developmental
disorders (including autism); 2—intellectual disability; 3—psychiatric
disorders; 4—nervous disorders (including blindness and deafness);
5—congenital anomalies (including Down syndrome); 6—respiratory
disorders; 7—other.
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.

VOID

CORRECTED

ISSUER'S name, street address, city or town, state or province, country, and 1 ABLE contributions
ZIP or foreign postal code

OMB No. 1545-2262

2017

$
2 Rollover contributions

$
ISSUER’S federal identification no.

BENEFICIARY'S social security number

BENEFICIARY'S name

Street address (including apt. no.)

4 Fair market value

$

$

5 Check if account opened
in 2017

6 Basis of eligibility

City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)
Form 5498-QA

Form 5498-QA

3 Cumulative contributions

7 Code

www.irs.gov/form5498qa

ABLE Account
Contribution
Information
Copy C
For Issuer
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2017 General
Instructions for
Certain
Information
Returns.

Department of the Treasury - Internal Revenue Service

Instructions for Issuer
To complete Form 5498-QA, use:
• the 2017 General Instructions for Certain Information
Returns, and
• the 2017 Instructions for Form 5498-QA.
To get or to order these instructions, go to
www.irs.gov/form5498qa.
Due dates. Furnish Copy B of this form to the
beneficiary (participant) by March 15, 2018.

File Copy A of this form with the IRS by May 31, 2018.
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).