Form 5498-Sa - Hsa, Archer Msa, Or Medicare Advantage Msa Information - 2012
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1
2
3
4
52727
VOID
CORRECTED
TRUSTEE’S name, street address, city, state, and ZIP code
1 Employee or self-employed
OMB No. 1545-1518
person’s Archer MSA
HSA, Archer MSA, or
contributions made in 2012
2012
and 2013 for 2012
Medicare Advantage
$
MSA Information
2 Total contributions made in 2012
5498-SA
$
Form
Copy A
TRUSTEE’S federal identification number PARTICIPANT'S social security number
3 Total HSA or Archer MSA contributions made in 2013 for 2012
$
For
Internal Revenue
PARTICIPANT'S name
4 Rollover contributions
5 Fair market value of HSA,
Archer MSA, or MA MSA
Service Center
$
$
File with Form 1096.
For Privacy Act and
Street address (including apt. no.)
6 HSA
Paperwork
Archer MSA
Reduction Act
City, state, and ZIP code
MA
Notice, see
MSA
the 2012 General
Instructions for
Account number (see instructions)
Certain Information
Returns.
5498-SA
Form
Cat. No. 38467V
Department of the Treasury - Internal Revenue Service
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