Form 5498-SA

HSA, Archer MSA, or MA MSA Information

Contributions and fair market value of HSA/MSA accounts.

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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 nameBusiness name (line 2)Individual first nameIndividual middle nameIndividual last nameForeign addressCheck to enter a non-US address (country + province + postal code).Address line 1 *Address line 2City *State (US address)Required for a US address.ZIP code (US address)Province / region (foreign)Country code (foreign)Two-letter ISO country code for a foreign address.Postal code (foreign)Phone number

Recipient / payee

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

Recipient TINTIN typeBusiness name controlBusiness nameBusiness name (line 2)Individual first nameIndividual middle nameIndividual last nameAdditional recipientForeign addressCheck to enter a non-US address (country + province + postal code).Address line 1 *Address line 2City *State (US address)Required for a US address.ZIP code (US address)Province / region (foreign)Country code (foreign)Two-letter ISO country code for a foreign address.Postal code (foreign)Account numberDistinguishes this recipient if you file more than one of the same form for them.

Filing details

Tax year *VoidCorrected

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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