Form 5498-Sa - Hsa, Archer Msa, Or Medicare Advantage Msa Information - 2012 Page 4
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1
2
3
4
5VOID
CORRECTED
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
Copy C
TRUSTEE’S federal identification number PARTICIPANT'S social security number
3 Total HSA or Archer MSA contributions made in 2013 for 2012
$
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
2012 General
City, state, and ZIP 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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