Form 5498-SA (Rev. December 2026)

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2727

CORRECTED

TRUSTEE’S name
Street address
City/town

Room/suite no.
State/province

Country

ZIP/foreign code

1 Employee’s or selfOMB No. 1545-1518
employed person’s Archer
MSA contributions made in
Form 5498-SA
the calendar year and the
subsequent year for the
(Rev. December 2026)
calendar year
For calendar year

HSA, Archer MSA, or
Medicare Advantage
MSA Information

$
2 Total contributions made in the calendar year

Telephone number:
TRUSTEE’S TIN

PARTICIPANT’S TIN

$
3 Total HSA or Archer MSA contributions made in the
subsequent year for the calendar year

PARTICIPANT’S name

$
Street address
City/town

State/province

Country

Archer MSA
MA MSA

www.irs.gov/Form1099

4 Rollover contributions

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

ZIP/foreign code

$

$

6 HSA

Form 5498-SA (Rev. 12-2026) Created 9/18/25

Cat. No. 38467V

For
Internal Revenue
Service Center
For filing information,
Privacy Act, and
Paperwork Reduction
Act Notice, see the
General Instructions
for Certain
Information Returns.

Apt. no.

Account number (see instructions)

Copy A

www.irs.gov/Form5498SA

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/town

Room/suite no.
State/province

Country

ZIP/foreign code

OMB No. 1545-1518
1 Employee’s or selfemployed person’s Archer
MSA contributions made in
Form 5498-SA
the calendar year and the
subsequent year for the
(Rev. December 2026)
calendar year
For calendar year

HSA, Archer MSA, or
Medicare Advantage
MSA Information

$
2 Total contributions made in the calendar year

Telephone number:
TRUSTEE’S TIN

PARTICIPANT’S TIN

$
3 Total HSA or Archer MSA contributions made in the
subsequent year for the calendar year

PARTICIPANT’S name

$
Street address
City/town

State/province

Country

Apt. no.

4 Rollover contributions

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

ZIP/foreign code

$

$

Copy B
For
Participant
This information
is being furnished
to the IRS.

6 HSA
Account number (see instructions)

Archer MSA
MA MSA

Form 5498-SA (Rev. 12-2026)

(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 makes 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 in the calendar year and through April 15 of the
subsequent year to your Archer MSA. You may be able to deduct this amount on your
Form 1040 or 1040-SR. See the Instructions for Form 1040.
Note: The information in boxes 2 and 3 is provided for IRS use only.
Box 2. Shows the total contributions made to your HSA or Archer MSA in the calendar
year shown on this form. 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 the subsequent year
for the calendar year shown on this form.
Box 4. Shows any rollover contribution from an Archer MSA to this Archer MSA in the
calendar year shown on this form 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 the calendar year shown on this form.
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.
Free File Program. Go to www.irs.gov/FreeFile to see if you qualify for no-cost online
federal tax preparation, e-filing, and direct deposit or payment options.