4 Rollover contributions

$

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

Fair market value of HSA,

Archer MSA, or MA MSA

5

$

PARTICIPANT’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (see instructions)

Form 5498-SA Department of the Treasury - Internal RCat. No. 38467V

Form 5498-SA

3 Total HSA or Archer MSA contributions made in 2011 for 2010

$

$

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4 Rollover contributions

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

Fair market value of HSA,

Archer MSA, or MA MSA

5

$

PARTICIPANT’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (see instructions)

Form 5498-SA (keep for your records) Department of the Treasury - Internal R

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3 Total HSA or Archer MSA contributions made in 2011 for 2010

$

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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.

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

MSA in 2010 or any rollover from an HSA or Archer MSA to this 

included are qualified HSA distributions (direct transfers) from a 

spending arrangement (FSA) or health reimbursement arrangem

fund an HSA. See Form 8853 or Form 8889 and their instructio

information about how to report distributions and rollovers. This 

included in box 1, 2, or 3.

Box 5. Shows the fair market value of your HSA, Archer MSA, o

the end of 2010.

Other information. The trustee of your HSA, Archer MSA, or M

provide other information about your account on this form.

Note. Do not attach Form 5498-SA to your income tax return. I

for your records.

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

2010.

HSA funding distributions (trustee-to-trustee transfers) from you

your HSA. The trustee of your MA MSA is not required to, but m

contributions to your MA MSA.

Box 6. Shows the type of account that is reported on this Form 

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.

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.

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.

Participant’s identification number. For your protection, this form may show

only the last four digits of your SSN, ITIN, or ATIN. However, the issuer has

reported your complete identification number to the IRS, and, where

applicable, to state and/or local governments.
Fo

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4 Rollover contributions

$

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

Fair market value of HSA,

Archer MSA, or MA MSA

5

$

PARTICIPANT’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (see instructions)

Form 5498-SA Department of the Treasury - Internal R

Form 5498-SA

3 Total HSA or Archer MSA contributions made in 2011 for 2010

$

$

6 HSA

Archer

MSA

MA

MSA
software that generates a file according 

specifications in Pub. 1220, Specification

Filing Forms 1098, 1099, 3921, 3922, 54

and W-2G Electronically. IRS does not p

fill-in form option.

Caution: Because paper forms are scanned

during processing, you cannot file Forms 1096,

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

from the IRS website.

Returns and the 2010 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

the IRS website at www.irs.gov or call

1-800-TAX-FORM (1-800-829-3676). Need help? If you have questions about 

on Form 5498-SA, call the information re

customer service site toll free at 1-866-4

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

equipment, call 304-579-4827 (not toll fr

hours of operation are Monday through 

from 8:30 a.m. to 4:30 p.m., Eastern tim