Form 5498-Sa - Hsa, Archer Msa, Or Medicare Advantage Msa Information - 2013 Page 2
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6VOID
CORRECTED
2727
TRUSTEE’S name, street address, city or town, province or state, 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 2013
2013
and 2014 for 2013
Medicare Advantage
$
MSA Information
2 Total contributions made in 2013
5498-SA
$
Form
Copy A
TRUSTEE’S federal identification number PARTICIPANT'S social security number
3 Total HSA or Archer MSA contributions made in 2014 for 2013
$
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, province or state, country, and ZIP or foreign postal code
MA
MSA
the 2013 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
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