Form 5498-Sa - Hsa, Archer Msa, Or Medicare Advantage Msa Information
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1CORRECTED (if checked)
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 2017
2017
and 2018 for 2017
Medicare Advantage
STATE BANK
$
MSA Information
123 MAIN ST
2 Total contributions made in 2017
YOUR CITY, STATE, ZIP
5498-SA
$
Form
3,500.00
TRUSTEE’S federal identification number PARTICIPANT'S social security number
3 Total HSA or Archer MSA contributions made in 2018 for 2017
Copy B
$
56-400XXXX
560-00-XXXX
0.00
PARTICIPANT'S name
4 Rollover contributions
5 Fair market value of HSA,
For
Archer MSA, or MA MSA
Participant
ANDREW T NOBLE
$
$
14,650.00
Street address (including apt. no.)
6 HSA
X
Archer MSA
1244 E. STATE ST.
This information
is being furnished
City or town, state or province, country, and ZIP or foreign postal code
MA
MSA
to the Internal
YOUR CITY, STATE, ZIP
Revenue Service.
Account number (see instructions)
5498-SA
Form
(keep for your records)
Department of the Treasury - Internal Revenue Service
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