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

Instructions for Participant

Account number. May show an account or other unique number the trustee

assigned to distinguish your account.

This information is submitted to the Internal Revenue Service by the trustee of

Box 1. Shows contributions you made to your Archer MSA in 2013 and through

your health savings account (HSA), Archer MSA, or Medicare Advantage MSA

April 15, 2014, for 2013. You may be able to deduct this amount on your 2013

(MA MSA).

Form 1040. See the Form 1040 instructions.

Generally, contributions you make to your Archer MSA are deductible.

Note. The information in boxes 2 and 3 is provided for IRS use only.

Employer contributions are excluded from your income and are not deductible

Box 2. Shows the total contributions made in 2013 to your HSA or Archer MSA.

by you. If your employer makes a contribution to one of your Archer MSAs, you

See Pub. 969 for who can make contributions. This includes qualified HSA

cannot contribute to any Archer MSA for that year. If you made a contribution to

funding distributions (trustee-to-trustee transfers) from your IRA to fund your

your Archer MSA when your employer has contributed, you cannot deduct your

HSA. The trustee of your MA MSA is not required to, but may, show

contribution, and you will have an excess contribution. If your spouse’s

contributions to your MA MSA.

employer makes a contribution to your spouse’s Archer MSA, you cannot make

Box 3. Shows the total HSA or Archer MSA contributions made in 2014 for

a contribution to your Archer MSA if your spouse is covered under a high

2013.

deductible health plan that also covers you.

Box 4. Shows any rollover contribution from an Archer MSA to this Archer MSA

Contributions that the Social Security Administration makes to your MA MSA

in 2013 or any rollover from an HSA or Archer MSA to this HSA. See Form 8853

are not includible in your gross income nor are they deductible. Neither you nor

or Form 8889 and their instructions for information about how to report

your employer can make contributions to your MA MSA.

distributions. This amount is not included in box 1, 2, or 3.

Generally, contributions you or someone other than your employer make to

Box 5. Shows the fair market value of your HSA, Archer MSA, or MA MSA at the

your HSA are deductible on your tax return. Employer contributions to your HSA

end of 2013.

may be excluded from your income and are not deductible by you. You and your

Box 6. Shows the type of account that is reported on this Form 5498-SA.

employer can make contributions to your HSA in the same year.

Other information. The trustee of your HSA, Archer MSA, or MA MSA may

See Form 8853 and its instructions or Form 8889 and its instructions. Any

provide other information about your account on this form.

employer contributions made to an Archer MSA are shown on your Form W-2 in

Note. Do not attach Form 5498-SA to your income tax return. Instead, keep it

box 12 (code R); employer contributions made to an HSA are shown in box 12

for your records.

(code W). For more information, see Pub. 969.

Future developments. For the latest information about developments related to

Participant's identification number. For your protection, this form may show

Form 5498-SA and its instructions, such as legislation enacted after the form

only the last four digits of your social security number (SSN), individual taxpayer

and instructions were published, go to

identification number (ITIN), or adoption taxpayer identification number (ATIN).

However, the issuer has reported your complete identification number to the IRS

and, where applicable, to state and/or local governments.

Form 5498-Sa - Hsa, Archer Msa, Or Medicare Advantage Msa Information - 2013 Page 4

Related Articles

Related forms

Related Categories