Form 5498-SA

2021

Cat. No. 38467V

HSA, Archer MSA, or 

Medicare Advantage 

MSA Information

Copy A

For 

Internal Revenue 

Service Center

Department of the Treasury - Internal Revenue Service

File with Form 1096.

OMB No. 1545-1518

For Privacy Act and 

Paperwork 

Reduction Act 

Notice, see 

the 2021 General

Instructions for 

Certain Information

Returns.

2727 VOID CORRECTED

TRUSTEE’S name, street address, city or town, state or province, country, 

ZIP or foreign postal code, and telephone number

TRUSTEE’S TIN PARTICIPANT'S TIN

PARTICIPANT'S name

Street address (including apt. no.)

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

Account number (see instructions)

1 Employee or self-employed 

person’s Archer MSA 

contributions made in 2021 

and 2022 for 2021

$

2 Total contributions made in 2021

$

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

$

4 Rollover contributions

$

5 Fair market value of HSA, 

Archer MSA, or MA MSA

$

6 HSA

Archer MSA

MA 

MSA

Form 5498-SA www.irs.gov/Form5498SA

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

Form 5498-SA

2021 HSA, Archer MSA, or 

Medicare Advantage 

MSA Information

Copy B

For 

Participant

Department of the Treasury - Internal Revenue Service

OMB No. 1545-1518

This information 

is being furnished 

to the IRS.

CORRECTED (if checked)

TRUSTEE’S name, street address, city or town, state or province, country, 

ZIP or foreign postal code, and telephone number

TRUSTEE’S TIN PARTICIPANT'S TIN

PARTICIPANT'S name

Street address (including apt. no.)

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

Account number (see instructions)

1 Employee or self-employed 

person’s Archer MSA 

contributions made in 2021 

and 2022 for 2021

$

2 Total contributions made in 2021

$

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

$

4 Rollover contributions

$

5 Fair market value of HSA, 

Archer MSA, or MA MSA

$

6 HSA

Archer MSA

MA 

MSA

Form 5498-SA (keep for your records) www.irs.gov/Form5498SA
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.
 

Form 5498-SA

2021 HSA, Archer MSA, or 

Medicare Advantage 

MSA Information

Copy C

For Trustee

Department of the Treasury - Internal Revenue Service

OMB No. 1545-1518

For Privacy Act 

and Paperwork 

Reduction Act 

Notice, see the 

2021 General

Instructions for 

Certain 

Information

Returns.

VOID CORRECTED

TRUSTEE’S name, street address, city or town, state or province, country, 

ZIP or foreign postal code, and telephone number

TRUSTEE’S TIN PARTICIPANT'S TIN

PARTICIPANT'S name

Street address (including apt. no.)

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

Account number (see instructions)

1 Employee or self-employed 

person’s Archer MSA 

contributions made in 2021 

and 2022 for 2021

$

2 Total contributions made in 2021

$

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

$

4 Rollover contributions

$

5 Fair market value of HSA, 

Archer MSA, or MA MSA

$

6 HSA

Archer MSA

MA 

MSA

Form 5498-SA www.irs.gov/Form5498SA
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).