Form 5498-Sa - Hsa, Archer Msa, Or Medicare Advantage Msa Information - 2018
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5VOID
CORRECTED
2727
TRUSTEE’S name, street address, city or town, state or province, country,
1 Employee or self-employed
OMB No. 1545-1518
ZIP or foreign postal code, and telephone number
person’s Archer MSA
HSA, Archer MSA, or
contributions made in 2018
2018
and 2019 for 2018
Medicare Advantage
$
MSA Information
2 Total contributions made in 2018
5498-SA
$
Form
Copy A
TRUSTEE’S TIN
PARTICIPANT'S TIN
3 Total HSA or Archer MSA contributions made in 2019 for 2018
$
For
Internal Revenue
PARTICIPANT'S name
4 Rollover contributions
5 Fair market value of HSA,
Service Center
Archer MSA, or MA MSA
$
$
File with Form 1096.
For Privacy Act and
Street address (including apt. no.)
6 HSA
Paperwork
Archer MSA
Reduction Act
Notice, see
City or town, state or province, country, and ZIP or foreign postal code
MA
MSA
the 2018 General
Instructions for
Account number (see instructions)
Certain Information
Returns.
5498-SA
Form
Cat. No. 38467V
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
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Parent category: Financial