VOID CORRECTED

Employee or self-employed person’s

Archer MSA contributions made in

2009 and 2010 for 2009

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 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 Revenue Service

2727

Cat. No. 38467V

Form 5498-SA

OMB No. 1545-1518

Total contributions made

in 2009

2

3 Total HSA or Archer MSA contributions made in 2010 for 2009

$

$

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 Advantage

MSA Information

File with Form 1096.

For Privacy Act and

Paperwork

Reduction Act

Notice, see

the 2009 General

Instructions for

Forms 1099, 1098,

3921, 3922, 5498,

and W-2G.

Copy A

For

Internal Revenue

Service Center

Archer

MSA

MA

MSA

2009
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

2009 and 2010 for 2009

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 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 Revenue Service

Form 5498-SA

OMB No. 1545-1518

Total contributions made

in 2009

2

3 Total HSA or Archer MSA contributions made in 2010 for 2009

$

$

6 HSA

HSA, Archer MSA, or

Medicare Advantage

MSA Information

Archer

MSA

MA

MSA

2009
Instructions for Participant

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.

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

only.

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

MSA in 2009 or any rollover from an HSA or Archer MSA to this HSA. Also

included are qualified HSA distributions (direct transfers) from a health flexible

spending arrangement (FSA) or health reimbursement arrangement (HRA) to

fund an HSA. 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 MA MSA at

the end of 2009.

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.

Box 3. Shows the total HSA or Archer MSA contributions made in 2010 for

2009.

Box 1. Shows contributions you made to your Archer MSA in 2009 and

through April 15, 2010, for 2009. You may be able to deduct this amount on

your 2009 Form 1040. See the Form 1040 instructions.

Box 2. Shows the total contributions made in 2009 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 6. Shows the type of account that is reported on this Form 5498-SA.

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, 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 an HSA are shown

in box 12 (code W).

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

Tax-Favored Health Plans.

Account number. May show an account or other unique number the trustee

assigned to distinguish your account.

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 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.
VOID CORRECTED

Copy C

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2009 General

Instructions for

Forms 1099,

1098, 3921, 3922,

5498, and W-2G.

For Trustee

Employee or self-employed person’s

Archer MSA contributions made in

2009 and 2010 for 2009

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 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 Revenue Service

Form 5498-SA

OMB No. 1545-1518

Total contributions made

in 2009

2

3 Total HSA or Archer MSA contributions made in 2010 for 2009

$

$

6 HSA

HSA, Archer MSA, or

Medicare Advantage

MSA Information

Archer

MSA

MA

MSA

2009
Instructions for Trustees

Due dates. Furnish Copy B of this form to the

participant by June 1, 2010.

File Copy A of this form with the IRS by June 1,

2010. To file electronically, you must have

software that generates a file according to the

specifications in Pub. 1220, Specifications for

Filing Forms 1098, 1099, 3921, 3922, 5498, and

W-2G Electronically. IRS does not provide a 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.

General and specific form instructions are

provided as separate products. The products you

should use to complete Form 5498-SA are the

2009 General Instructions for Forms 1099, 1098,

3921, 3922, 5498, and W-2G and the 2009

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 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 304-267-3367 (not toll free).