Form 5498-Sa - Hsa, Archer Msa, Or Medicare Advantage Msa Information - 2018 Page 3
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5Instructions for Participant
Account number. May show an account or other unique number the trustee
assigned to distinguish your account.
This information is submitted to the IRS by the trustee of your health savings
Box 1. Shows contributions you made to your Archer MSA in 2018 and through
account (HSA), Archer medical savings account (MSA), or Medicare Advantage
April 15, 2019, for 2018. You may be able to deduct this amount on your 2018
MSA (MA MSA).
Form 1040. See the Form 1040 instructions.
Generally, contributions you make to your Archer MSA are deductible.
Note: The information in boxes 2 and 3 is provided for IRS use only.
Employer contributions are excluded from your income and aren't deductible by
Box 2. Shows the total contributions made in 2018 to your HSA or Archer MSA.
you. If your employer makes a contribution to one of your Archer MSAs, you
See Pub. 969 for who can make contributions. This includes qualified HSA
can't contribute to any Archer MSA for that year. If you made a contribution to
funding distributions (trustee-to-trustee transfers) from your IRA to fund your
your Archer MSA when your employer has contributed, you can't deduct your
HSA. The trustee of your MA MSA isn't required to, but may, show contributions
contribution, and you will have an excess contribution. If your spouse’s
to your MA MSA.
employer makes a contribution to your spouse’s Archer MSA, you can't make a
Box 3. Shows the total HSA or Archer MSA contributions made in 2019 for
contribution to your Archer MSA if your spouse is covered under a high
2018.
deductible health plan that also covers you.
Box 4. Shows any rollover contribution from an Archer MSA to this Archer MSA
Contributions that the Social Security Administration makes to your MA MSA
in 2018 or any rollover from an HSA or Archer MSA to this HSA. See Form 8853
aren't includible in your gross income nor are they deductible. Neither you nor
or Form 8889 and their instructions for information about how to report
your employer can make contributions to your MA MSA.
distributions. This amount isn't included in box 1, 2, or 3.
Generally, contributions you or someone other than your employer make to
Box 5. Shows the fair market value of your HSA, Archer MSA, or MA MSA at the
your HSA are deductible on your tax return. Employer contributions to your HSA
end of 2018.
may be excluded from your income and aren't deductible by you. You and your
Box 6. Shows the type of account that is reported on this Form 5498-SA.
employer can make contributions to your HSA in the same year.
Other information. The trustee of your HSA, Archer MSA, or MA MSA may
See Form 8853 and its instructions or Form 8889 and its instructions. Any
provide other information about your account on this form.
employer contributions made to an Archer MSA are shown on your Form W-2 in
Note: Don't attach Form 5498-SA to your income tax return. Instead, keep it for
box 12 (code R); employer contributions made to an HSA are shown in box 12
your records.
(code W). For more information, see Pub. 969.
Future developments. For the latest information about developments related to
Participant's taxpayer identification number (TIN). For your protection, this
Form 5498-SA and its instructions, such as legislation enacted after they were
form may show only the last four digits of your social security number (SSN),
published, go to
individual taxpayer identification number (ITIN), adoption taxpayer identification
number (ATIN), or employer identification number (EIN). However, the issuer has
reported your complete TIN to the IRS.
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