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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 IRS by the trustee of your health savings Box 1. Shows contributions you made to your Archer MSA in 2023 and through
account (HSA), Archer medical savings account (MSA), or Medicare Advantage April 15, 2024, for 2023. You may be able to deduct this amount on your 2023
MSA (MA MSA). Form 1040 or 1040-SR. See the Instructions for Form 1040.
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 aren’t deductible by Box 2. Shows the total contributions made in 2023 to your HSA or Archer MSA.
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
can’t 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 can’t deduct your HSA. The trustee of your MA MSA isn’t required to, but may, show contributions
contribution, and you will have an excess contribution. If your spouse’s to your MA MSA.
employer makes a contribution to your spouse’s Archer MSA, you can’t make a Box 3. Shows the total HSA or Archer MSA contributions made in 2024 for
contribution to your Archer MSA if your spouse is covered under a high 2023.
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 2023 or any rollover from an HSA or Archer MSA to this HSA. See Form 8853
aren’t 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 isn’t 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 2023.
may be excluded from your income and aren’t 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.
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: Don’t attach Form 5498-SA to your income tax return. Instead, keep it for
(code W). For more information, see Pub. 969. your records.
Participant’s taxpayer identification number (TIN). For your protection, this Future developments. For the latest information about developments related to
form may show only the last four digits of your social security number (SSN), Form 5498-SA and its instructions, such as legislation enacted after they were
individual taxpayer identification number (ITIN), adoption taxpayer identification published, go to www.irs.gov/Form5498SA.
number (ATIN), or employer identification number (EIN). However, the issuer has Free File Program. Go to www.irs.gov/FreeFile to see if you qualify for no-cost
reported your complete TIN to the IRS. online federal tax preparation, e-filing, and direct deposit or payment options.
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