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⚠️ Notice: This information collection may be referencing outdated material.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 2014 HSA, Archer MSA, or Medicare Advantage MSA Information Form
i1099-sa_and_5498_sa--2014-00-00[1].pdf Instruction
i1099-sa_and_5498_sa--2015-00-00[1].pdf Instruction
Form 5498-SA 2014 HSA, Archer MSA, or Medicare Advantage MSA Information f5498-sa--2014-00-00[1].pdf Form
5498-SA 2015 HSA, Archer MSA, or Medicare Advantage MSA Information f5498-sa--2015-00-00[1].pdf Form
Burden-F5498-SA-2014.PDF 2014 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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Form 5498-SA 2014	HSA, Archer MSA, or Medicare Advantage MSA Information	f5498-sa--2014-00-00[1].pdf	Yes	No	Paper Only
Form	5498-SA 2015	HSA, Archer MSA, or Medicare Advantage MSA Information	f5498-sa--2015-00-00[1].pdf	Yes	No	Paper Only
Instruction			i1099-sa_and_5498_sa--2014-00-00[1].pdf	Yes	Yes	Paper Only
Instruction			i1099-sa_and_5498_sa--2015-00-00[1].pdf	Yes	Yes	Paper Only

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 9,167	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	9,167	-43,050	52,217
Annual IC Time Burden (Hours)	1,559	-7,318	8,877
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
2014 Burden	Burden-F5498-SA-2014.PDF	11/21/2014

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