Form 5498-Sa - Hsa, Archer Msa, Or Medicare Advantage Msa Information - 2017 Page 2
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1
2
3
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 2017
2017
and 2018 for 2017
Medicare Advantage
$
MSA Information
2 Total contributions made in 2017
5498-SA
$
Form
TRUSTEE’S federal identification number PARTICIPANT'S social security number
3 Total HSA or Archer MSA contributions made in 2018 for 2017
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
is being furnished
City or town, state or province, country, and ZIP or foreign postal code
MA
MSA
to the Internal
Revenue Service.
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