Form 5498-Sa - Hsa, Archer Msa, Or Medicare Advantage Msa Information - 2018 Page 2
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4
5CORRECTED (if checked)
TRUSTEE’S name, street address, city or town, state or province, country,
1 Employee or self-employed
OMB No. 1545-1518
ZIP or foreign postal code, and telephone number
person’s Archer MSA
HSA, Archer MSA, or
contributions made in 2018
2018
and 2019 for 2018
Medicare Advantage
$
MSA Information
2 Total contributions made in 2018
5498-SA
$
Form
TRUSTEE’S TIN
PARTICIPANT'S TIN
3 Total HSA or Archer MSA contributions made in 2019 for 2018
Copy B
$
PARTICIPANT'S name
4 Rollover contributions
5 Fair market value of HSA,
For
Archer MSA, or MA MSA
Participant
$
$
Street address (including apt. no.)
6 HSA
Archer MSA
This information
City or town, state or province, country, and ZIP or foreign postal code
MA
is being furnished
MSA
to the IRS.
Account number (see instructions)
5498-SA
Form
(keep for your records)
Department of the Treasury - Internal Revenue Service
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Parent category: Financial