Form 5498-Sa - Hsa, Archer Msa, Or Medicare Advantage Msa Information - 2014 Page 4
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6Instructions 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 your
Box 1. Shows contributions you made to your Archer MSA in 2014 and through
health savings account (HSA), Archer MSA, or Medicare Advantage MSA (MA MSA).
April 15, 2015, for 2014. You may be able to deduct this amount on your 2014
Generally, contributions you make to your Archer MSA are deductible.
Form 1040. See the Form 1040 instructions.
Employer contributions are excluded from your income and are not deductible
Note. The information in boxes 2 and 3 is provided for IRS use only.
by you. If your employer makes a contribution to one of your Archer MSAs, you
Box 2. Shows the total contributions made in 2014 to your HSA or Archer MSA.
cannot contribute to any Archer MSA for that year. If you made a contribution to
See Pub. 969 for who can make contributions. This includes qualified HSA
your Archer MSA when your employer has contributed, you cannot deduct your
funding distributions (trustee-to-trustee transfers) from your IRA to fund your
contribution, and you will have an excess contribution. If your spouse’s
HSA. The trustee of your MA MSA is not required to, but may, show
employer makes a contribution to your spouse’s Archer MSA, you cannot make
contributions to your MA MSA.
a contribution to your Archer MSA if your spouse is covered under a high
Box 3. Shows the total HSA or Archer MSA contributions made in 2015 for
deductible health plan that also covers you.
2014.
Contributions that the Social Security Administration makes to your MA MSA
Box 4. Shows any rollover contribution from an Archer MSA to this Archer MSA
are not includible in your gross income nor are they deductible. Neither you nor
in 2014 or any rollover from an HSA or Archer MSA to this HSA. See Form 8853
your employer can make contributions to your MA MSA.
or Form 8889 and their instructions for information about how to report
Generally, contributions you or someone other than your employer make to
distributions. This amount is not included in box 1, 2, or 3.
your HSA are deductible on your tax return. Employer contributions to your HSA
Box 5. Shows the fair market value of your HSA, Archer MSA, or MA MSA at the
may be excluded from your income and are not deductible by you. You and your
end of 2014.
employer can make contributions to your HSA in the same year.
Box 6. Shows the type of account that is reported on this Form 5498-SA.
See Form 8853 and its instructions or Form 8889 and its instructions. Any
Other information. The trustee of your HSA, Archer MSA, or MA MSA may
employer contributions made to an Archer MSA are shown on your Form W-2 in
provide other information about your account on this form.
box 12 (code R); employer contributions made to an HSA are shown in box 12
Note. Do not attach Form 5498-SA to your income tax return. Instead, keep it
(code W). For more information, see Pub. 969.
for your records.
Participant's identification number. For your protection, this form may show
Future developments. For the latest information about developments related to
only the last four digits of your social security number (SSN), individual taxpayer
Form 5498-SA and its instructions, such as legislation enacted after they were
identification number (ITIN), or adoption taxpayer identification number (ATIN).
published, go to
However, the issuer has reported your complete identification number to the IRS
and, where applicable, to state and/or local governments.
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