Form 5498-SA HSA, ARCHER MSA OR MEDICARE ADVANTAGE MSA INFORMATION

2727

VOID

CORRECTED

TRUSTEE’S name, street address, city or town, state or province, country,
ZIP or foreign postal code, and telephone number

1 Employee or self-employed
person’s Archer MSA
contributions made in 2021
and 2022 for 2021

OMB No. 1545-1518

2021

$
2 Total contributions made in 2021

Form 5498-SA

$
TRUSTEE’S TIN

PARTICIPANT'S TIN

HSA, Archer MSA, or
Medicare Advantage
MSA Information

3 Total HSA or Archer MSA contributions made in 2022 for 2021

$
PARTICIPANT'S name

4 Rollover contributions

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

$

$

6 HSA

Street address (including apt. no.)

Archer MSA
City or town, state or province, country, and ZIP or foreign postal code

MA
MSA

Account number (see instructions)
Form 5498-SA

Cat. No. 38467V

www.irs.gov/Form5498SA

Copy A
For
Internal Revenue
Service Center
File with Form 1096.
For Privacy Act and
Paperwork
Reduction Act
Notice, see
the 2021 General
Instructions for
Certain Information
Returns.

Department of the Treasury - Internal Revenue Service

Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page

CORRECTED (if checked)
TRUSTEE’S name, street address, city or town, state or province, country,
ZIP or foreign postal code, and telephone number

1 Employee or self-employed
person’s Archer MSA
contributions made in 2021
and 2022 for 2021

OMB No. 1545-1518

2021

$
2 Total contributions made in 2021

Form 5498-SA

$
TRUSTEE’S TIN

PARTICIPANT'S TIN

HSA, Archer MSA, or
Medicare Advantage
MSA Information

3 Total HSA or Archer MSA contributions made in 2022 for 2021

$
PARTICIPANT'S name

4 Rollover contributions

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

$

$

Copy B
For
Participant

6 HSA

Street address (including apt. no.)

Archer MSA
City or town, state or province, country, and ZIP or foreign postal code

MA
MSA

This information
is being furnished
to the IRS.

Account number (see instructions)
Form 5498-SA

(keep for your records)

www.irs.gov/Form5498SA

Department of the Treasury - Internal Revenue Service

Instructions for Participant
This information is submitted to the IRS by the trustee of your health savings
account (HSA), Archer medical savings account (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 aren’t deductible by
you. If your employer makes a contribution to one of your Archer MSAs, you
can’t contribute to any Archer MSA for that year. If you made a contribution to
your Archer MSA when your employer has contributed, you can’t 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 can’t 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
aren’t 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 aren’t deductible by you. You and your
employer can make contributions to your HSA in the same year.
See Form 8853 and its instructions or Form 8889 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.
Participant’s taxpayer identification number (TIN). For your protection, this
form may show only the last four digits of your social security number (SSN),
individual taxpayer identification number (ITIN), adoption taxpayer identification
number (ATIN), or employer identification number (EIN). However, the issuer has
reported your complete TIN to the IRS.

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 2021 and through
April 18, 2022, for 2021. You may be able to deduct this amount on your 2021
Form 1040 or 1040-SR. See the Instructions for Forms 1040 and 1040-SR.
Note: The information in boxes 2 and 3 is provided for IRS use only.
Box 2. Shows the total contributions made in 2021 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 isn’t required to, but may, show contributions
to your MA MSA.
Box 3. Shows the total HSA or Archer MSA contributions made in 2022 for
2021.
Box 4. Shows any rollover contribution from an Archer MSA to this Archer MSA
in 2021 or any rollover from an HSA or Archer MSA to this HSA. See Form 8853
or Form 8889 and their instructions for information about how to report
distributions. This amount isn’t 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 2021.
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: Don’t attach Form 5498-SA to your income tax return. Instead, keep it for
your records.
Future developments. For the latest information about developments related to
Form 5498-SA and its instructions, such as legislation enacted after they were
published, go to www.irs.gov/Form5498SA.

VOID

CORRECTED

TRUSTEE’S name, street address, city or town, state or province, country,
ZIP or foreign postal code, and telephone number

1 Employee or self-employed
person’s Archer MSA
contributions made in 2021
and 2022 for 2021

OMB No. 1545-1518

2021

$
2 Total contributions made in 2021

Form 5498-SA

$
TRUSTEE’S TIN

PARTICIPANT'S TIN

HSA, Archer MSA, or
Medicare Advantage
MSA Information

3 Total HSA or Archer MSA contributions made in 2022 for 2021

$
PARTICIPANT'S name

4 Rollover contributions

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

$

$

6 HSA

Street address (including apt. no.)

Archer MSA
City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)
Form 5498-SA

www.irs.gov/Form5498SA

MA
MSA

Copy C
For Trustee
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2021 General
Instructions for
Certain
Information
Returns.

Department of the Treasury - Internal Revenue Service

Instructions for Trustee
To complete Form 5498-SA, use:
• The 2021 General Instructions for Certain Information
Returns, and
• The 2021 Instructions for Forms 1099-SA and
5498-SA.
To get and to order these instructions, go to
www.irs.gov/Form5498SA.
Due dates. Furnish Copy B of this form to the
participant by May 31, 2022.
File Copy A of this form with the IRS by May 31, 2022.
To file electronically, you must have software that

generates a file according to the specifications in Pub.
1220.
Future developments. For the latest information about
developments related to Form 5498-SA and its
instructions, such as legislation enacted after they were
published, go to www.irs.gov/Form5498SA.
Need help? If you have questions about reporting on
Form 5498-SA, call the information reporting customer
service site toll free at 866-455-7438 or 304-263-8700
(not toll free). Persons with a hearing or speech
disability with access to TTY/TDD equipment can call
304-579-4827 (not toll free).