Exhibit V
Internal Revenue Bulletin 2003-16 · 2026-10-03 edition · updated 2026-10-04 · United States
Coverdell ESA
Contribution
Information
Copy A
For Internal Revenue
Service Center
File with Form 1096.
For Privacy Act
and Paperwork
Reduction Act Notice, see the
2003 General Instructions for Forms 1099, 1098,
5498, and W-2G.
.50"
| CORREC VOID 2727 | CTED | ||
|---|---|---|---|
| TRUSTEE’S or ISSUER’S name, street address, city, state, and ZIP code 3.40" |
TRUSTEE’S or ISSUER’S name, street address, city, state, and ZIP code 3.40" |
Coverdell ESA contributions 1 $ |
Form5498-ESA OMB No. 1545-1815 2003 |
| TRUSTEE’S or ISSUER’S name, street address, city, state, and ZIP code 3.40" |
TRUSTEE’S or ISSUER’S name, street address, city, state, and ZIP code 3.40" |
Rollover contributions 2 $ |
Rollover contributions 2 $ |
| TRUSTEE’S or ISSUER’S Federal identification no. | BENEFICIARY’S social security number | 1.40" |
|
| BENEFICIARY’S name | BENEFICIARY’S name | ||
| Street address (including apt. no.) | Street address (including apt. no.) | ||
| City, state, and ZIP code | City, state, and ZIP code | City, state, and ZIP code | City, state, and ZIP code |
| Account number (optional) | Account number (optional) | Account number (optional) | Account number (optional) |
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
Coverdell ESA
Contribution
Information
Copy A
For Internal Revenue
Service Center
File with Form 1096.
For Privacy Act
and Paperwork
Reduction Act Notice, see the
2003 General Instructions for Forms 1099, 1098,
5498, and W-2G.
| 2727 CORREC VOID | CTED | ||
|---|---|---|---|
| TRUSTEE’S or ISSUER’S name, street address, city, state, and ZIP code | TRUSTEE’S or ISSUER’S name, street address, city, state, and ZIP code | Coverdell ESA contributions 1 $ |
Form5498-ESA OMB No. 1545-1815 2003 |
| TRUSTEE’S or ISSUER’S name, street address, city, state, and ZIP code | TRUSTEE’S or ISSUER’S name, street address, city, state, and ZIP code | Rollover contributions 2 $ |
Rollover contributions 2 $ |
| TRUSTEE’S or ISSUER’S Federal identification no. | BENEFICIARY’S social security number | ||
| BENEFICIARY’S name | BENEFICIARY’S name | ||
| Street address (including apt. no.) | Street address (including apt. no.) | ||
| City, state, and ZIP code | City, state, and ZIP code | City, state, and ZIP code | City, state, and ZIP code |
| Account number (optional) | Account number (optional) | Account number (optional) | Account number (optional) |
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
Contribution
Information
Copy A
For Internal Revenue
Service Center
File with Form 1096.
For Privacy Act
and Paperwork
Reduction Act Notice, see the
2003 General Instructions for Forms 1099, 1098,
5498, and W-2G.
| 2727 CORREC VOID | CTED | ||
|---|---|---|---|
| TRUSTEE’S or ISSUER’S name, street address, city, state, and ZIP code | TRUSTEE’S or ISSUER’S name, street address, city, state, and ZIP code | Coverdell ESA contributions 1 $ |
Form5498-ESA OMB No. 1545-1815 2003 |
| TRUSTEE’S or ISSUER’S name, street address, city, state, and ZIP code | TRUSTEE’S or ISSUER’S name, street address, city, state, and ZIP code | Rollover contributions 2 $ |
Rollover contributions 2 $ |
| TRUSTEE’S or ISSUER’S Federal identification no. | BENEFICIARY’S social security number | ||
| BENEFICIARY’S name | BENEFICIARY’S name | ||
| Street address (including apt. no.) | Street address (including apt. no.) | ||
| City, state, and ZIP code | City, state, and ZIP code | City, state, and ZIP code | City, state, and ZIP code |
| Account number (optional) | Account number (optional) | Account number (optional) | Account number (optional) |
Form 5498-ESA Cat. No. 34011J Department of the Treasury - Internal Revenue Service
April 21, 2003 799 2003–16 I.R.B.
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