Form 5498-SA

2015

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 2015 General

Instructions for 

Certain Information

Returns.

2727 VOID CORRECTED

TRUSTEE’S name, street address, city or town, state or province, country, 

ZIP or foreign postal code, and telephone number

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

PARTICIPANT'S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

Account number (see instructions)

1 Employee or self-employed 

person’s Archer MSA 

contributions made in 2015 

and 2016 for 2015

$

2 Total contributions made in 2015

$

3 Total HSA or Archer MSA contributions made in 2016 for 2015

$

4 Rollover contributions

$

5 Fair market value of HSA, 

Archer MSA, or MA MSA

$

6 HSA

Archer MSA

MA 

MSA

Form 5498-SA www.irs.gov/form5498sa

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

Form 5498-SA

2015 HSA, Archer MSA, or 

Medicare Advantage 

MSA Information

Copy B

For 

Participant

Department of the Treasury - Internal Revenue Service

OMB No. 1545-1518

This information 

is being furnished 

to the Internal 

Revenue Service.

CORRECTED (if checked)

TRUSTEE’S name, street address, city or town, state or province, country, 

ZIP or foreign postal code, and telephone number

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

PARTICIPANT'S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

Account number (see instructions)

1 Employee or self-employed 

person’s Archer MSA 

contributions made in 2015 

and 2016 for 2015

$

2 Total contributions made in 2015

$

3 Total HSA or Archer MSA contributions made in 2016 for 2015

$

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) www.irs.gov/form5498sa
Instructions for Participant

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

health savings account (HSA), Archer medical savings account (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), adoption taxpayer identification number (ATIN), or 

employer identification number (EIN). However, the issuer has reported your 

complete identification number to the IRS.

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 2015 and through 

April 18, 2016, for 2015. You may be able to deduct this amount on your 2015 

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 2015 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 2016 for

2015.

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

in 2015 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 2015.

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.

Future developments. For the latest information about developments related to 

Form 5498-SA and its instructions, such as legislation enacted after they were 

published, go to www.irs.gov/form5498sa.
 

Form 5498-SA

2015 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 

2015 General

Instructions for 

Certain 

Information

Returns.

VOID CORRECTED

TRUSTEE’S name, street address, city or town, state or province, country, 

ZIP or foreign postal code, and telephone number

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

PARTICIPANT'S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

Account number (see instructions)

1 Employee or self-employed 

person’s Archer MSA 

contributions made in 2015 

and 2016 for 2015

$

2 Total contributions made in 2015

$

3 Total HSA or Archer MSA contributions made in 2016 for 2015

$

4 Rollover contributions

$

5 Fair market value of HSA, 

Archer MSA, or MA MSA

$

6 HSA

Archer MSA

MA 

MSA

Form 5498-SA www.irs.gov/form5498sa
Instructions for Trustee

To complete Form 5498-SA, use:

• the 2015 General Instructions for Certain Information 

Returns, and 

• the 2015 Instructions for Forms 1099-SA and 

5498-SA.

To order these instructions and additional forms, go 

to www.irs.gov/form5498sa or call 1-800-TAX-FORM 

(1-800-829-3676).

Due dates. Furnish Copy B of this form to the

participant by May 31, 2016.

File Copy A of this form with the IRS by May 31, 2016. 

To file electronically, you must have software that

generates a file according to the specifications in Pub. 

1220, Specifications for Electronic Filing of Forms 1097, 

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

Future developments. For the latest information about 

developments related to Form 5498-SA and its 

instructions, such as legislation enacted after they were 

published, go to www.irs.gov/form5498sa.

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). Persons with a hearing or speech 

disability with access to TTY/TDD equipment can call 

304-579-4827 (not toll free).