Form 5498-Sa - Hsa, Archer Msa, Or Medicare Advantage Msa Information - 2012 Page 2
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1
2
3
4
5CORRECTED (if checked)
TRUSTEE’S name, street address, city, state, and ZIP code
1 Employee or self-employed
OMB No. 1545-1518
person’s Archer MSA
HSA, Archer MSA, or
contributions made in 2012
2012
and 2013 for 2012
Medicare Advantage
$
MSA Information
2 Total contributions made in 2012
5498-SA
$
Form
TRUSTEE’S federal identification number PARTICIPANT'S social security number
3 Total HSA or Archer MSA contributions made in 2013 for 2012
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
The information
Archer MSA
in boxes 1 through
City, state, and ZIP code
6 is being
MA
MSA
furnished to the
Internal Revenue
Account number (see instructions)
Service.
5498-SA
Form
(keep for your records)
Department of the Treasury - Internal Revenue Service
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