Instructions For Forms 1099-Sa And 5498-Sa

you need not file Form 5498-SA nor furnish a statement to the

participant to reflect that the FMV on December 31 was zero.

Box 1. Employee or Self-Employed Person's

Archer MSA Contributions Made in 2014 and 2015

Death of Account Holder

for 2014

In the year an HSA, Archer MSA, or MA MSA owner dies, generally

Enter the employee's or self-employed person's regular

you must file a Form 5498-SA and furnish a statement for the

contributions to the Archer MSA made in 2014 and through April 15,

decedent. If the designated beneficiary is the spouse:

2015, for 2014. Report gross contributions, including any excess

The spouse becomes the account holder of the HSA or Archer

contributions, even if the excess contributions were withdrawn. No

MSA.

HSA information is to be reported in box 1.

An MA MSA is treated as an Archer MSA of the spouse for

distribution purposes, but no new contributions may be made to the

Box 2. Total Contributions Made in 2014

account.

Enter the total HSA or Archer MSA contributions made in 2014.

If the designated beneficiary is not the spouse or there is no

Include any contribution made in 2014 for 2013. Also include

designated beneficiary, the account ceases to be an HSA, Archer

qualified HSA funding distributions (trustee-to-trustee transfers from

MSA, or MA MSA.

an IRA to an HSA under section 408(d)(9)) received by you during

2014. Any excess employer contributions (and the earnings on

Statements to Participants

them) withdrawn by the employer pursuant to Notice 2008-59, Q/A

24, available at , should not

If you are required to file Form 5498-SA, you must provide a

be reported as a contribution. You may, but you are not required to,

statement to the participant (generally Copy B) by June 1, 2015. You

report the total MA MSA contributions the Secretary of Health and

may, but you are not required to, provide participants with a

Human Services or his or her representative made in 2014. Do not

statement of the December 31, 2014, FMV of the participant's

include amounts reported in box 4.

account by January 31, 2015. For more information about

statements to participants, see part M in the 2014 General

Box 3. Total HSA or Archer MSA Contributions

Instructions for Certain Information Returns.

Made in 2015 for 2014

If you furnished a statement of the FMV of the account to the

Enter the total HSA or Archer MSA contributions made in 2015 for

participant by January 31, 2015, and no reportable contributions,

2014.

including rollovers, were made for 2014, you need not furnish

another statement (or Form 5498-SA) to the participant to report

Box 4. Rollover Contributions

zero contributions. However, you must file Form 5498-SA with the

IRS by June 1, 2015, to report the December 31, 2014, FMV of the

Enter rollover contributions to the HSA or Archer MSA received by

account.

you during 2014. These amounts are not to be included in box 2.

If you do not furnish another statement to the participant

because no reportable contributions were made for the

Box 5. Fair Market Value of HSA, Archer MSA, or

year, the statement of the FMV of the account must contain

MA MSA

CAUTION

a legend designating which information is being furnished to the

Internal Revenue Service.

Enter the FMV of the account on December 31, 2014.

Box 6. Checkbox

Account Number

Check the box to indicate if this account is an HSA, Archer MSA, or

The account number is required if you have multiple accounts for a

MA MSA.

recipient for whom you are filing more than one Form 5498-SA.

Additionally, the IRS encourages you to designate an account

number for all Forms 5498-SA that you file. See part L in the 2014

General Instructions for Certain Information Returns.

Instructions for Forms 1099-SA and 5498-SA (2014)

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Instructions For Forms 1099-Sa And 5498-Sa - 2014 Page 3

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