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

Form 5498-Sa - Hsa, Archer Msa, Or Medicare Advantage Msa Information - 2013 Page 5

VOID

CORRECTED

1 Employee or self-employed

OMB No. 1545-1518

TRUSTEE’S name, street address, city or town, province or state, country,

person’s Archer MSA

ZIP or foreign postal code, and telephone number

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 C

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

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

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

2013 General

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

Instructions for

MSA

Certain

Information

Account number (see instructions)

Returns.

5498-SA

Form

Department of the Treasury - Internal Revenue Service

Form 5498-Sa - Hsa, Archer Msa, Or Medicare Advantage Msa Information - 2013 Page 5