Form 5498-SA 2014 Form 5498-SA 2014 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
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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 or town, state or province, country,
ZIP or foreign postal code, and telephone number

1 Employee or self-employed
person’s Archer MSA
contributions made in 2014
and 2015 for 2014

OMB No. 1545-1518

2014

$
2 Total contributions made in 2014

Form 5498-SA

$
TRUSTEE’S federal identification number PARTICIPANT'S social security number

HSA, Archer MSA, or
Medicare Advantage
MSA Information

3 Total HSA or Archer MSA contributions made in 2015 for 2014

$
PARTICIPANT'S name

4 Rollover contributions

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

$

$

6 HSA

Street address (including apt. no.)

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

MA
MSA

Account number (see instructions)
Form 5498-SA

Cat. No. 38467V

www.irs.gov/form5498sa

Copy A
For
Internal Revenue
Service Center
File with Form 1096.
For Privacy Act and
Paperwork
Reduction Act
Notice, see
the 2014 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 (if checked)
TRUSTEE’S name, street address, city or town, state or province, country,
ZIP or foreign postal code, and telephone number

1 Employee or self-employed
person’s Archer MSA
contributions made in 2014
and 2015 for 2014

OMB No. 1545-1518

2014

$
2 Total contributions made in 2014

Form 5498-SA

$
TRUSTEE’S federal identification number PARTICIPANT'S social security number

HSA, Archer MSA, or
Medicare Advantage
MSA Information

3 Total HSA or Archer MSA contributions made in 2015 for 2014

$
PARTICIPANT'S name

4 Rollover contributions

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

$

$

6 HSA

Street address (including apt. no.)

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

MA
MSA

Account number (see instructions)
Form 5498-SA

(keep for your records)

www.irs.gov/form5498sa

Copy B
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.
Participant'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
assigned to distinguish your account.
Box 1. Shows contributions you made to your Archer MSA in 2014 and through
April 15, 2015, for 2014. You may be able to deduct this amount on your 2014
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 2014 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 2015 for
2014.
Box 4. Shows any rollover contribution from an Archer MSA to this Archer MSA
in 2014 or any rollover from an HSA or Archer MSA to this HSA. See Form 8853
or Form 8889 and their instructions for information about how to report
distributions. 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 2014.
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.
Future developments. For the latest information about developments related to
Form 5498-SA and its instructions, such as legislation enacted after they were
published, go to www.irs.gov/form5498sa.

VOID

CORRECTED

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

1 Employee or self-employed
person’s Archer MSA
contributions made in 2014
and 2015 for 2014

OMB No. 1545-1518

2014

$
2 Total contributions made in 2014

Form 5498-SA

$
TRUSTEE’S federal identification number PARTICIPANT'S social security number

HSA, Archer MSA, or
Medicare Advantage
MSA Information

3 Total HSA or Archer MSA contributions made in 2015 for 2014

$
PARTICIPANT'S name

4 Rollover contributions

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

$

$

6 HSA

Street address (including apt. no.)

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

www.irs.gov/form5498sa

MA
MSA

Copy C
For Trustee
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2014 General
Instructions for
Certain
Information
Returns.

Department of the Treasury - Internal Revenue Service

Instructions for Trustee
To complete Form 5498-SA, use:
• the 2014 General Instructions for Certain Information
Returns, and
• the 2014 Instructions for Forms 1099-SA and
5498-SA.
To order these instructions and additional forms, go
to www.irs.gov/form5498sa 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 June 1, 2015.
File Copy A of this form with the IRS by June 1,
2015. To file electronically, you must have software that

generates a file according to the specifications in Pub.
1220, Specifications for Electronic Filing of Forms 1097,
1098, 1099, 3921, 3922, 5498, 8935, and W-2G. The
IRS does not provide a fill-in form option.
Future developments. For the latest information about
developments related to Form 5498-SA and its
instructions, such as legislation enacted after they were
published, go to www.irs.gov/form5498sa.
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). Persons with a hearing or speech
disability with access to TTY/TDD equipment can call
304-579-4827 (not toll free).