VOID CORRECTED

Employee or self-employed person’s

Archer MSA contributions made in

2004 and 2005 for 2004

TRUSTEE’S name, street address, city, state, and ZIP code 1

$

4 Rollover contributions

$

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

Fair market value of HSA,

Archer MSA, or M+C MSA

5

$

PARTICIPANT’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (optional)

Form 5498-SA Department of the Treasury - Internal Revenue Service

2727

Cat. No. 38467V

Form 5498-SA

OMB No. 1545-1518

Total contributions made

in 2004

2

3 Total HSA or Archer MSA contributions made in 2005 for 2004

$

$

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

6 HSA

HSA, Archer MSA, or

Medicare+Choice

MSA Information

File with Form 1096.

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2004 General

Instructions for

Forms 1099, 1098,

5498, and W-2G.

Copy A

For

Internal Revenue

Service Center

2004

Archer

MSA

M+C

MSA
CORRECTED (if checked)

For

Participant

Copy B

The information

in boxes 1 through

6 is being

furnished to the

Internal Revenue

Service.

Employee or self-employed person’s

Archer MSA contributions made in

2004 and 2005 for 2004

TRUSTEE’S name, street address, city, state, and ZIP code 1

$

4 Rollover contributions

$

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

Fair market value of HSA,

Archer MSA, or M+C MSA

5

$

PARTICIPANT’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (optional)

Form 5498-SA (Keep for your records) Department of the Treasury - Internal Revenue Service

Form 5498-SA

OMB No. 1545-1518

Total contributions made

in 2004

2

3 Total HSA or Archer MSA contributions made in 2005 for 2004

$

$

6 HSA

HSA, Archer MSA, or

Medicare+Choice

MSA Information 2004

Archer

MSA

M+C

MSA
Instructions to Participant

This information is submitted to the Internal Revenue Service by the

trustee of your Health Savings Account (HSA), Archer MSA, or

Medicare+Choice MSA (M+C MSA).

Generally, contributions you make to your HSA or Archer MSA are

deductible. However, employer contributions to your HSA are not

deductible. 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.

Note: The information in boxes 2 and 3 is provided by the trustee for IRS

use only.

Box 4. Shows any rollover contribution you made to this Archer MSA in

2004 after a distribution from another Archer MSA or shows any rollover

to this HSA from another HSA or Archer MSA. See Form 8853 or Form

8889 and their instructions for information about how to report

distributions and rollovers. This amount is not included in box 1, 2, or 3.

Box 5. Shows the fair market value of your HSA, Archer MSA, or M+C

MSA at the end of 2004.

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

Box 3. Shows the total HSA or Archer MSA contributions made in 2005

for 2004.

Box 1. Shows employee or self-employed person’s Archer MSA

contributions made to your Archer MSA in 2004 and through April 15,

2005, for 2004. You may be able to deduct this amount on your 2004

Form 1040. See the Form 1040 instructions.

Other Tax-Favored Health Plans.

Box 2. Shows the total employer and employee/self-employed

contributions made in 2004 to your HSA or Archer MSA. The trustee of

your M+C MSA is not required to, but may, show contributions to your

M+C MSA.

Box 6. Shows the type of account that is reported on this Form 5498-SA.

Contributions that the Social Security Administration makes to your

M+C MSA are not includible in your gross income nor are they

deductible. Neither you nor your employer can make contributions to

your M+C MSA.

Note: Reference to a Medicare+Choice (M+C) MSA includes a Medicare

Advantage (MA) MSA.

See Form 8853, Archer MSAs and Long-Term Care Insurance Contracts,

and its instructions or Form 8889, Health Savings Accounts (HSAs) 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

HSAs are shown in Box 12 (code W).

For more information, see Pub. 969, Health Savings Accounts and
VOID CORRECTED

Copy C

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2004 General

Instructions for

Forms 1099,

1098, 5498,

and W-2G.

For Trustee

Employee or self-employed person’s

Archer MSA contributions made in

2004 and 2005 for 2004

TRUSTEE’S name, street address, city, state, and ZIP code 1

$

4 Rollover contributions

$

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

Fair market value of HSA,

Archer MSA, or M+C MSA

5

$

PARTICIPANT’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (optional)

Form 5498-SA Department of the Treasury - Internal Revenue Service

Form 5498-SA

OMB No. 1545-1518

Total contributions made

in 2004

2

3 Total HSA or Archer MSA contributions made in 2005 for 2004

$

$

6 HSA

HSA, Archer MSA, or

Medicare+Choice

MSA Information 2004

Archer

MSA

M+C

MSA
Instructions for Trustees

Due dates. Furnish Copy B of this form to

the participant by May 31, 2005.

File Copy A of this form with the IRS by

May 31, 2005.

Caution: Because paper forms are scanned

during processing, you cannot file Forms

1096, 1098, 1099, or 5498 that you download

and print from the IRS website.

General and specific form instructions are

provided as separate products. The products

you should use to complete Form 5498-SA

are the 2004 General Instructions for Forms

1099, 1098, 5498, and W-2G, and the 2004

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, call

1-800-TAX-FORM (1-800-829-3676).