Form 5498-SA Form 5498-SA HSA, Archer MSA, or Medicare Advantage MSA 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.
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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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VOID

CORRECTED

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

1 Employee or self-employed person’s
Archer MSA contributions made in
2011 and 2012 for 2011

OMB No. 1545-1518

$

2011

2 Total contributions made
in 2011

Form 5498-SA

$
TRUSTEE’S federal identification number

HSA, Archer MSA, or
Medicare Advantage
MSA Information

PARTICIPANT’S social security number 3 Total HSA or Archer MSA contributions made in 2012 for 2011

$
PARTICIPANT’S name

Street address (including apt. no.)

4 Rollover contributions

5 Fair market value of HSA,
Archer MSA, or MA MSA

$

$

6 HSA
Archer
MSA
MA
MSA

City, state, and ZIP code

Account number (see instructions)

Form

5498-SA

Cat. No. 38467V

Do Not Cut or Separate Forms on This Page

—

Copy A
For
Internal Revenue
Service Center
File with Form 1096.

For Privacy Act and
Paperwork
Reduction Act
Notice, see
the 2011 General
Instructions
for Certain
Information
Returns.

Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page

CORRECTED (if checked)
TRUSTEE’S name, street address, city, state, and ZIP code

1 Employee or self-employed person’s
Archer MSA contributions made in
2011 and 2012 for 2011

OMB No. 1545-1518

2011

$
2 Total contributions made
in 2011

$
TRUSTEE’S federal identification number

HSA, Archer MSA, or
Medicare Advantage
MSA Information

Form 5498-SA

PARTICIPANT’S social security number 3 Total HSA or Archer MSA contributions made in 2012 for 2011

$
PARTICIPANT’S name

4 Rollover contributions

$
Street address (including apt. no.)

6 HSA
Archer
MSA
MA
MSA

City, state, and ZIP code

Account number (see instructions)

Form

5498-SA

(keep for your records)

Copy B
5 Fair market value of HSA,
Archer MSA, or MA MSA

$

For
Participant
The information
in boxes 1 through
6 is being
furnished to the
Internal Revenue
Service.

Department of the Treasury - Internal Revenue Service

Instructions for Participant
This information is submitted to the Internal Revenue Service by the trustee of
your health savings account (HSA), Archer MSA, or Medicare Advantage MSA
(MA MSA).
Generally, contributions you make to your Archer MSA are deductible.
Employer contributions are excluded from your income and are not deductible
by you. If your employer makes a contribution to one of your Archer MSAs,
you cannot contribute to any Archer MSA for that year. If you made a
contribution to your Archer MSA when your employer has contributed, you
cannot deduct your contribution, and you will have an excess contribution. If
your spouse’s employer makes a contribution to your spouse’s Archer MSA,
you cannot make a contribution to your Archer MSA if your spouse is covered
under a high deductible health plan that also covers you.
Contributions that the Social Security Administration makes to your
MA MSA are not includible in your gross income nor are they deductible.
Neither you nor your employer can make contributions to your MA MSA.
Generally, contributions you or someone other than your employer make to
your HSA are deductible on your tax return. Employer contributions to your
HSA may be excluded from your income and are not deductible by you. You
and your employer can make contributions to your HSA in the same year.
See Form 8853 and its instructions or Form 8889 and its instructions. Any
employer contributions made to an Archer MSA are shown on your Form W-2 in
box 12 (code R); employer contributions made to an HSA are shown in box 12
(code W). For more information, see Pub. 969.
Account number. May show an account or other unique number the trustee
assigned to distinguish your account.

Box 1. Shows contributions you made to your Archer MSA in 2011 and
through April 17, 2012, for 2011. You may be able to deduct this amount on
your 2011 Form 1040. See the Form 1040 instructions.
Note. The information in boxes 2 and 3 is provided for IRS use only.
Box 2. Shows the total contributions made in 2011 to your HSA or Archer
MSA. See Pub. 969 for who can make contributions. This includes qualified
HSA funding distributions (trustee-to-trustee transfers) from your IRA to fund
your HSA. The trustee of your MA MSA is not required to, but may, show
contributions to your MA MSA.
Box 3. Shows the total HSA or Archer MSA contributions made in 2012 for
2011.
Box 4. Shows any rollover contribution from an Archer MSA to this Archer
MSA in 2011 or any rollover from an HSA or Archer MSA to this HSA. Also
included are qualified HSA distributions (direct transfers) from a health flexible
spending arrangement (FSA) or health reimbursement arrangement (HRA) to
fund an HSA. See Form 8853 or Form 8889 and their instructions for
information about how to report distributions and rollovers. This amount is not
included in box 1, 2, or 3.
Box 5. Shows the fair market value of your HSA, Archer MSA, or MA MSA at
the end of 2011.
Box 6. Shows the type of account that is reported on this Form 5498-SA.
Other information. The trustee of your HSA, Archer MSA, or MA MSA may
provide other information about your account on this form.
Note. Do not attach Form 5498-SA to your income tax return. Instead, keep it
for your records.

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

CORRECTED
1 Employee or self-employed person’s
Archer MSA contributions made in
2011 and 2012 for 2011

OMB No. 1545-1518

$

2011

2 Total contributions made
in 2011

$
TRUSTEE’S federal identification number

HSA, Archer MSA, or
Medicare Advantage
MSA Information

Form 5498-SA

PARTICIPANT’S social security number 3 Total HSA or Archer MSA contributions made in 2012 for 2011

$
PARTICIPANT’S name

4 Rollover contributions

$
Street address (including apt. no.)

City, state, and ZIP code

Account number (see instructions)

Form

5498-SA

6 HSA
Archer
MSA
MA
MSA

5 Fair market value of HSA,
Archer MSA, or MA MSA

$

Copy C
For Trustee
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2011 General
Instructions for
Certain
Information
Returns.

Department of the Treasury - Internal Revenue Service

Instructions for Trustee
General and specific form instructions are
provided as separate products. The products you
should use to complete Form 5498-SA are the
2011 General Instructions for Certain Information
Returns and the 2011 Instructions for Forms
1099-SA and 5498-SA. A chart in the general
instructions gives a quick guide to which form
must be filed to report a particular payment. 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 Forms 1096,
1097, 1098, 1099, 3921, 3922, or 5498 that you
print from the IRS website.

Due dates. Furnish Copy B of this form to the
participant by May 31, 2012.
File Copy A of this form with the IRS by May
31, 2012. 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-SA, 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.