Form 5498-SA

HSA, Archer MSA, or MA MSA Information

Contributions and fair market value of HSA/MSA accounts.

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Original returns for tax year 2025 only. A corrected return has to name the original by the ID the IRS gave it, so corrections open once originals have been filed through us. One recipient per return.

Issuer / payer

The business or person that paid and is filing this return. Enter either a business name or an individual name.

Foreign entityIssuer TIN *TIN type *Business name controlFirst 4 significant characters of the business name.Business nameLetters, numbers, spaces and # - ( ) & ' only. Leave out periods and commas: Acme Inc, not Acme, Inc.Business name (line 2)Individual name controlFirst 4 letters of the individual's last name.Individual first nameLetters, hyphens and spaces only. Leave out apostrophes and periods: OBrien, not O'Brien.Individual middle nameIndividual last nameSuffixForeign addressTick for an address outside the United States: it has a country, and no state or ZIP code.Address line 1 *Letters, numbers, spaces, hyphens and slashes only. Leave out periods, commas and #.Address line 2CityLetters and spaces only: Winston Salem, St Louis.State (U.S. address)ZIP code (U.S. address)Phone number *

Recipient / payee

The person or business that received the payment. Enter either a business name or an individual name.

Recipient TINLeave it empty only if the recipient did not give you one. The IRS accepts the return and reports the TIN as missing.TIN typeBusiness name controlBusiness nameLetters, numbers, spaces and # - ( ) & ' only. Leave out periods and commas: Acme Inc, not Acme, Inc.Business name (line 2)Individual name controlFirst 4 letters of the individual's last name.Individual first nameLetters, hyphens and spaces only. Leave out apostrophes and periods: OBrien, not O'Brien.Individual middle nameIndividual last nameSuffixAdditional recipientForeign addressTick for an address outside the United States: it has a country, and no state or ZIP code.Address line 1 *Letters, numbers, spaces, hyphens and slashes only. Leave out periods, commas and #.Address line 2CityLetters and spaces only: Winston Salem, St Louis.State (U.S. address)ZIP code (U.S. address)Account numberDistinguishes this recipient if you file more than one of the same form for them.

Filing details

Tax year *Issuer office codeFour characters, if you use one to tell your offices apart.

Form 5498-SA details

1Archer MSA contributions made in this and prior year2Total contributions made this year3Total HSA or Archer MSA contributions made next year for this year4Rollover contributions5Fair market value of HSA, Archer MSA, or MA MSA6HSA6Archer MSA6MA MSA

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