Information Collection

HSA, Archer MSA, or Medicare Advantage MSA Information

IC 18582 under ICR 201411-1545-053 · OMB 1545-1518.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form 5498-SA 2014 HSA, Archer MSA, or Medicare Advantage MSA Information HSA, Archer MSA, or Medicare Advantage MSA Information	Form
Form 5498-SA 2015 HSA, Archer MSA, or Medicare Advantage MSA Information 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

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:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Form 5498-SA 2014	Yes	No	Paper Only
Form	5498-SA 2015	Yes	No	Paper Only
Instruction		Yes	Yes	Paper Only
Instruction		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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
2014 Burden		11/21/2014

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

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