Form 5498-Sa - Hsa, Archer Msa, Or Medicare Advantage Msa Information

Form 5498-Sa - Hsa, Archer Msa, Or Medicare Advantage Msa Information - 2013 Page 3

CORRECTED (if checked)

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

TRUSTEE’S federal identification number PARTICIPANT'S social security number

3 Total HSA or Archer MSA contributions made in 2014 for 2013

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

6 is being

City or town, province or state, country, and ZIP or foreign postal code

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

Form 5498-Sa - Hsa, Archer Msa, Or Medicare Advantage Msa Information - 2013 Page 3