HSA, Archer MSA, or Medicare Advantage MSA Information

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1545-1518 can be found here:

Documents and Forms

Document Name Document Type
Form Form 5498-SA HSA, Archer MSA, or Medicare Advantage MSA Information Form and Instruction
Inst_Form5498-SA 2011.pdf Instruction
Form 5498-SA HSA, Archer MSA, or Medicare Advantage MSA Information Form 5498-SA.pdf Form and Instruction
Burden.PDF Burden IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	HSA, Archer MSA, or Medicare Advantage MSA Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form 5498-SA	HSA, Archer MSA, or Medicare Advantage MSA Information	Form 5498-SA.pdf		Yes	No	Paper Only
Instruction			Inst_Form5498-SA 2011.pdf		Yes	No	Printable Only

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 52,217	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 95 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	52,217	11,112	41,105
Annual IC Time Burden (Hours)	8,877	1,889	6,988
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Burden	Burden.PDF	10/19/2011

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.