Form 5498-Sa - Hsa, Archer Msa, Or Medicare Advantage Msa Information - 2017 Page 4
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1
2
3
4
5VOID
CORRECTED
1 Employee or self-employed
OMB No. 1545-1518
TRUSTEE’S name, street address, city or town, state or province, country,
person’s Archer MSA
ZIP or foreign postal code, and telephone number
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 C
TRUSTEE’S federal identification number PARTICIPANT'S social security number
3 Total HSA or Archer MSA contributions made in 2018 for 2017
$
For Trustee
PARTICIPANT'S name
4 Rollover contributions
5 Fair market value of HSA,
Archer MSA, or MA MSA
For Privacy Act
and Paperwork
$
$
Reduction Act
Street address (including apt. no.)
6 HSA
Notice, see the
Archer MSA
2017 General
City or town, state or province, country, and ZIP or foreign postal code
MA
Instructions for
MSA
Certain
Information
Account number (see instructions)
Returns.
5498-SA
Form
Department of the Treasury - Internal Revenue Service
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