Form 5498-SA HSA, Archer MSA, or Medicare Advantage MSA Information

2009 Form 5498-SA,
HSA, Archer MSA, or Medicare Advantage MSA Information
Purpose:

This is the first circulated draft of the 2009 Form5498-SA for
your review and comments. See below for a discussion of the
major changes.

TPCC
Meeting:

None, but one may be arranged if requested.

Prior
Version:

The 2008 Form 5498-SA is available at:
http://www.irs.gov/pub/irs-pdf/f5498sa.pdf

Instructions:

The 2009 Instructions for Forms 1099-SA and 5498-SA will be
circulated at a later date. The 2008 instructions are available at:
http://www.irs.gov/pub/irs-pdf/i1099sa.pdf

Other
Products:

Circulations of draft tax forms, instructions, notices, and
publications are posted at
http://taxforms.web.irs.gov/Circulations/index.htm

Comments:

Please email or fax any comments by June 6, 2008.

Melody G. DeVoe
Tax Law Specialist,
SE:W:CAR:MP:T:I:P
Phone: 202-283-7635
Fax: 202-283-2485
Email:[email protected]

Major Changes to the 2009 Form 5498-SA,
HSA, Archer MSA, or Medicare Advantage MSA Information
• All years and dates have been updated as appropriate.
• The hours of operation have been removed from the
Instructions for Trustees at the request of the Office of Notice
Gatekeeper. SE:W:CAS:AM:ESP

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I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 5498-SA, PAGE 1 OF 6 (Page 2 is blank)
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Date

Action

Date

Signature

O.K. to print
T:FP:F
O.K. to print
Responsible
scan organization
Revised proofs
requested

Separation 1—INK: Red, J-6983
Separation 2—INK: Black

2727

VOID

CORRECTED

TRUSTEE’S name, street address, city, state, and ZIP code

1 Employee or self-employed person’s
Archer MSA contributions made in
2009 and 2010 for 2009

OMB No. 1545-1518

$

2009

2 Total contributions made
in 2009

Form 5498-SA

$
TRUSTEE’S federal identification number

HSA, Archer MSA, or
Medicare Advantage
MSA Information

PARTICIPANT’S social security number 3 Total HSA or Archer MSA contributions made in 2010 for 2009

$
PARTICIPANT’S name

Street address (including apt. no.)

4 Rollover contributions

5 Fair market value of HSA,
Archer MSA, or MA MSA

$

$

6 HSA
Archer
MSA
MA
MSA

City, state, and ZIP code

Account number (see instructions)

Form

5498-SA

Cat. No. 38467V

Do Not Cut or Separate Forms on This Page

—

Copy A
For
Internal Revenue
Service Center
File with Form 1096.

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2009 General
Instructions for
Forms 1099, 1098,
5498, and W-2G.

Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page

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I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 5498-SA, PAGE 3 OF 6
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

CORRECTED (if checked)
TRUSTEE’S name, street address, city, state, and ZIP code

1 Employee or self-employed person’s
Archer MSA contributions made in
2009 and 2010 for 2009

OMB No. 1545-1518

2009

$
2 Total contributions made
in 2009

$
TRUSTEE’S federal identification number

HSA, Archer MSA, or
Medicare Advantage
MSA Information

Form 5498-SA

PARTICIPANT’S social security number 3 Total HSA or Archer MSA contributions made in 2010 for 2009

$
PARTICIPANT’S name

4 Rollover contributions

$
Street address (including apt. no.)

Copy B
5 Fair market value of HSA,
Archer MSA, or MA MSA

$

6 HSA
Archer
MSA
MA
MSA

City, state, and ZIP code

The information
in boxes 1 through
6 is being
furnished to the
Internal Revenue
Service.

Account number (see instructions)

Form

5498-SA

(keep for your records)

For
Participant

Department of the Treasury - Internal Revenue Service

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I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 5498-SA, PAGE 4 OF 6
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Instructions for Participant
This information is submitted to the Internal Revenue Service by the trustee of
your health savings account (HSA), Archer MSA, or Medicare Advantage MSA
(MA MSA).
Generally, contributions you make to your Archer MSA are deductible.
Employer contributions are excluded from your income and are not deductible
by you. If your employer makes a contribution to one of your Archer MSAs,
you cannot contribute to any Archer MSA for that year. If you made a
contribution to your Archer MSA when your employer has contributed, you
cannot deduct your contribution, and you will have an excess contribution. If
your spouse’s employer makes a contribution to your spouse’s Archer MSA,
you cannot make a contribution to your Archer MSA if your spouse is covered
under a high deductible health plan that also covers you.
Contributions that the Social Security Administration makes to your
MA MSA are not includible in your gross income nor are they deductible.
Neither you nor your employer can make contributions to your MA MSA.
Generally, contributions you or someone other than your employer make to
your HSA are deductible on your tax return. Employer contributions to your
HSA may be excluded from your income and are not deductible by you. You
and your employer can make contributions to your HSA in the same year.
See Form 8853, Archer MSAs and Long-Term Care Insurance Contracts, and
its instructions or Form 8889, Health Savings Accounts (HSAs), and its instructions. Any employer contributions made to an Archer MSA are shown on your
Form W-2 in box 12 (code R); employer contributions made to an HSA are shown
in box 12 (code W).
For more information, see Pub. 969, Health Savings Accounts and Other
Tax-Favored Health Plans.

Account number. May show an account or other unique number the trustee
assigned to distinguish your account.
Box 1. Shows contributions you made to your Archer MSA in 2009 and
through April 15, 2010, for 2009. You may be able to deduct this amount on
your 2009 Form 1040. See the Form 1040 instructions.
Note. The information in boxes 2 and 3 is provided by the trustee for IRS use
only.
Box 2. Shows the total contributions made in 2009 to your HSA or Archer
MSA. See Pub. 969 for who can make contributions. This includes qualified
HSA funding distributions (trustee-to-trustee transfers) from your IRA to fund
your HSA. The trustee of your MA MSA is not required to, but may, show
contributions to your MA MSA.
Box 3. Shows the total HSA or Archer MSA contributions made in 2010 for
2009.
Box 4. Shows any rollover contribution from an Archer MSA to this Archer
MSA in 2009 or any rollover from an HSA or Archer MSA to this HSA. Also
included are qualified HSA distributions (direct transfers) from a health flexible
spending arrangement (FSA) or health reimbursement arrangement (HRA) to
fund an HSA. See Form 8853 or Form 8889 and their instructions for
information about how to report distributions and rollovers. This amount is not
included in box 1, 2, or 3.
Box 5. Shows the fair market value of your HSA, Archer MSA, or MA MSA at
the end of 2009.
Box 6. Shows the type of account that is reported on this Form 5498-SA.
Other information. The trustee of your HSA, Archer MSA, or MA MSA may
provide other information about your account on this form.
Note. Do not attach Form 5498-SA to your income tax return. Instead, keep it
for your records.

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I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 5498-SA, PAGE 5 OF 6
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

VOID
TRUSTEE’S name, street address, city, state, and ZIP code

CORRECTED
1 Employee or self-employed person’s
Archer MSA contributions made in
2009 and 2010 for 2009

OMB No. 1545-1518

$

2009

2 Total contributions made
in 2009

$
TRUSTEE’S federal identification number

HSA, Archer MSA, or
Medicare Advantage
MSA Information

Form 5498-SA

PARTICIPANT’S social security number 3 Total HSA or Archer MSA contributions made in 2010 for 2009

$
PARTICIPANT’S name

4 Rollover contributions

$
Street address (including apt. no.)

City, state, and ZIP code

5 Fair market value of HSA,
Archer MSA, or MA MSA

$

6 HSA
Archer
MSA
MA
MSA

Account number (see instructions)

Form

5498-SA

Copy C
For Trustee
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2009 General
Instructions for
Forms 1099,
1098, 5498,
and W-2G.

Department of the Treasury - Internal Revenue Service

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I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 5498-SA, PAGE 6 OF 6
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Instructions for Trustees
General and specific form instructions are
provided as separate products. The products you
should use to complete Form 5498-SA are the
2009 General Instructions for Forms 1099, 1098,
5498, and W-2G and the 2009 Instructions for
Forms 1099-SA and 5498-SA. A chart in the
general instructions gives a quick guide to which
form must be filed to report a particular payment.
To order these instructions and additional forms,
visit the IRS website at www.irs.gov or call
1-800-TAX-FORM (1-800-829-3676).
Caution: Because paper forms are scanned
during processing, you cannot file Forms 1096,
1098, 1099, or 5498 that you download and print
from the IRS website.
Due dates. Furnish Copy B of this form to the
participant by June 1, 2010.

File Copy A of this form with the IRS by June 1,
2010. To file electronically, you must have
software that generates a file according to the
specifications in Pub. 1220, Specifications for
Filing Forms 1098, 1099, 5498, and W-2G
Electronically. IRS does not provide a fill-in form
option.
Need help? If you have questions about reporting
on Form 5498-SA, call the information reporting
customer service site toll free at 1-866-455-7438
or 304-263-8700 (not toll free). For TTY/TDD
equipment, call 304-267-3367 (not toll free).

Printed on recycled paper

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