VOID CORRECTED

Employee or self-employed person’s

Archer MSA contributions made in

2007 and 2008 for 2007

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 2007

2

3 Total HSA or Archer MSA contributions made in 2008 for 2007

$

$

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

2007 General

Instructions for

Forms 1099, 1098,

5498, and W-2G.

Copy A

For

Internal Revenue

Service Center

Archer

MSA

MA

MSA

2007
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

2007 and 2008 for 2007

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 2007

2

3 Total HSA or Archer MSA contributions made in 2008 for 2007

$

$

6 HSA

HSA, Archer MSA, or

Medicare Advantage

MSA Information

Archer

MSA

MA

MSA

2007
Instructions for Participant

What’s new. See boxes 2 and 4 for qualified HSA funding distributions added

by the Tax Relief and Health Care Act of 2006. Box 2 includes

trustee-to-trustee transfers from an IRA to an HSA. Box 4 includes direct

transfers from an HRA or an FSA to an HSA.

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 2007

after a distribution from another Archer MSA or shows any rollover to this HSA

from another HSA or Archer MSA. Also included are qualified HSA funding

distributions (direct transfers of employer contributions) 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 2007.

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 2008 for

2007.

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

made to your Archer MSA in 2007 and through April 15, 2008, for 2007. You

may be able to deduct this amount on your 2007 Form 1040. See the 

Form 1040 instructions.

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

made in 2007 to your HSA or Archer MSA. This includes qualified distributions

(trustee-to-trustee transfers) from an IRA to fund an 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 HSAs 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).
VOID CORRECTED

Copy C

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2007 General

Instructions for

Forms 1099,

1098, 5498,

and W-2G.

For Trustee

Employee or self-employed person’s

Archer MSA contributions made in

2007 and 2008 for 2007

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 2007

2

3 Total HSA or Archer MSA contributions made in 2008 for 2007

$

$

6 HSA

HSA, Archer MSA, or

Medicare Advantage

MSA Information

Archer

MSA

MA

MSA

2007
Instructions for Trustees

Due dates. Furnish Copy B of this form to the

participant by June 2, 2008.

File Copy A of this form with the IRS by June 2,

2008. To file electronically, you must have

software that generates a file according to the

specifications in Pub. 1220, Specifications for

Filing Forms 1098, 1099, 5498, and W-2G

Electronically or Magnetically. IRS does not

provide a fill-in form option.

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

2007 General Instructions for Forms 1099, 1098,

5498, and W-2G and the 2007 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). The

hours of operation are Monday through Friday

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

service site can also be reached by email at

mccirp@irs.gov.