Form 5498-Sa - Hsa, Archer Msa, Or Medicare Advantage Msa Information - 2017

Download a blank fillable Form 5498-Sa - Hsa, Archer Msa, Or Medicare Advantage Msa Information - 2017 in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 5498-Sa - Hsa, Archer Msa, Or Medicare Advantage Msa Information - 2017 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

VOID
CORRECTED
2727
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 2017
2017
and 2018 for 2017
Medicare Advantage
$
MSA Information
2 Total contributions made in 2017
5498-SA
$
Form
Copy A
TRUSTEE’S federal identification number PARTICIPANT'S social security number
3 Total HSA or Archer MSA contributions made in 2018 for 2017
$
For
Internal Revenue
PARTICIPANT'S name
4 Rollover contributions
5 Fair market value of HSA,
Service Center
Archer MSA, or MA MSA
$
$
File with Form 1096.
For Privacy Act and
Street address (including apt. no.)
6 HSA
Paperwork
Archer MSA
Reduction Act
Notice, see
City or town, state or province, country, and ZIP or foreign postal code
MA
MSA
the 2017 General
Instructions for
Account number (see instructions)
Certain Information
Returns.
5498-SA
Form
Cat. No. 38467V
Department of the Treasury - Internal Revenue Service
Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Financial
Go
Page of 5