Form 5498-SA

2012

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 2012 General

Instructions for 

Certain Information

Returns.

2727 VOID CORRECTED

TRUSTEE’S name, street address, city, state, and ZIP code

TRUSTEE’S federal identification number PARTICIPANT'S social security number

PARTICIPANT'S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (see instructions)

1 Employee or self-employed 

person’s Archer MSA 

contributions made in 2012 

and 2013 for 2012

$

2 Total contributions made in 2012

$

3 Total HSA or Archer MSA contributions made in 2013 for 2012

$

4 Rollover contributions

$

5 Fair market value of HSA, 

Archer MSA, or MA MSA

$

6 HSA

Archer MSA

MA 

MSA

Form 5498-SA

Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page
Form 5498-SA

2012 HSA, Archer MSA, or 

Medicare Advantage 

MSA Information

Copy B

For 

Participant

Department of the Treasury - Internal Revenue Service

OMB No. 1545-1518

The information 

in boxes 1 through 

6 is being 

furnished to the 

Internal Revenue 

Service.

CORRECTED (if checked)

TRUSTEE’S name, street address, city, state, and ZIP code

TRUSTEE’S federal identification number PARTICIPANT'S social security number

PARTICIPANT'S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (see instructions)

1 Employee or self-employed 

person’s Archer MSA 

contributions made in 2012 

and 2013 for 2012

$

2 Total contributions made in 2012

$

3 Total HSA or Archer MSA contributions made in 2013 for 2012

$

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)
Instructions for Participant

This information is submitted to the Internal Revenue Service by the trustee of 

your health savings account (HSA), Archer 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 are not deductible 

by you. If your employer makes a contribution to one of your Archer MSAs, you 

cannot contribute to any Archer MSA for that year. If you made a contribution to 

your Archer MSA when your employer has contributed, you cannot 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 cannot 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 

are not 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 are not 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 identification number. For your protection, this form may show 

only the last four digits of your social security number (SSN), individual taxpayer 

identification number (ITIN), or adoption taxpayer identification number (ATIN). 

However, the issuer has reported your complete identification number to the 

IRS, and, where applicable, to state and/or local governments.

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 2012 and through 

April 15, 2013, for 2012. You may be able to deduct this amount on your 2012 

Form 1040. See the Form 1040 instructions.

Note. The information in boxes 2 and 3 is provided for IRS use only.

Box 2. Shows the total contributions made in 2012 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 is not required to, but may, show

contributions to your MA MSA.

Box 3. Shows the total HSA or Archer MSA contributions made in 2013 for

2012.

Box 4. Shows any rollover contribution from an Archer MSA to this Archer MSA 

in 2012 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 is not 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 2012.

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. Do not attach Form 5498-SA to your income tax return. Instead, keep it

for your records.
Form 5498-SA

2012 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 

2012 General

Instructions for 

Certain 

Information

Returns.

VOID CORRECTED

TRUSTEE’S name, street address, city, state, and ZIP code

TRUSTEE’S federal identification number PARTICIPANT'S social security number

PARTICIPANT'S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (see instructions)

1 Employee or self-employed 

person’s Archer MSA 

contributions made in 2012 

and 2013 for 2012

$

2 Total contributions made in 2012

$

3 Total HSA or Archer MSA contributions made in 2013 for 2012

$

4 Rollover contributions

$

5 Fair market value of HSA, 

Archer MSA, or MA MSA

$

6 HSA

Archer MSA

MA 

MSA

Form 5498-SA
Instructions for Trustee

General and specific form instructions are provided 

as separate products. The products you should 

use to complete Form 5498-SA are the 2012 

General Instructions for Certain Information 

Returns and the 2012 Instructions for Forms 

1099-SA and 5498-SA. A chart in the general 

instructions gives a quick guide to which form 

must be filed to report a particular payment. To 

order these instructions and additional forms, visit 

IRS.gov or call 1-800-TAX-FORM 

(1-800-829-3676).

Caution: Because paper forms are scanned during 

processing, you cannot file Forms 1096, 1097, 

1098, 1099, 3921, 3922, or 5498 that you print 

from the IRS website.

Due dates. Furnish Copy B of this form to the

participant by May 31, 2013.

File Copy A of this form with the IRS by May 31, 

2013. To file electronically, you must have software 

that generates a file according to the specifications 

in Pub. 1220, Specifications for Filing Forms 1097, 

1098, 1099, 3921, 3922, 5498, 8935, and W-2G 

Electronically. IRS does not provide a fill-in form 

option.

Need help? If you have questions about reporting

on Form 5498-SA, call the information reporting

customer service site toll free at 1-866-455-7438

or 304-263-8700 (not toll free). For TTY/TDD

equipment, call 304-579-4827 (not toll free). The

hours of operation are Monday through Friday from 

8:30 a.m. to 4:30 p.m., Eastern time.