Enlarge image | 2727 VOID CORRECTED TRUSTEE’S name, street address, city or town, state or province, country, 1 Employee’s or self- OMB No. 1545-1518 ZIP or foreign postal code, and telephone number employed person’s Archer MSA contributions made in HSA, Archer MSA, or 2024 and 2025 for 2024 Medicare Advantage $ 2024 MSA Information 2 Total contributions made in 2024 $ Form 5498-SA TRUSTEE’S TIN PARTICIPANT’S TIN 3 Total HSA or Archer MSA contributions made in 2025 for 2024 Copy A $ For PARTICIPANT’S name 4 Rollover contributions 5 Fair market value of HSA, Internal Revenue Archer MSA, or MA MSA Service Center $ $ File with Form 1096. Street address (including apt. no.) 6 HSA For Privacy Act and Paperwork Archer MSA Reduction Act City or town, state or province, country, and ZIP or foreign postal code Notice, see MA MSA the 2024 General Instructions for Account number (see instructions) Certain Information Returns. Form 5498-SA Cat. No. 38467V www.irs.gov/Form5498SA Department of the Treasury - Internal Revenue Service Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page |
Enlarge image | CORRECTED (if checked) TRUSTEE’S name, street address, city or town, state or province, country, 1 Employee’s or self- OMB No. 1545-1518 ZIP or foreign postal code, and telephone number employed person’s Archer MSA contributions made in HSA, Archer MSA, or 2024 and 2025 for 2024 Medicare Advantage $ 2024 MSA Information 2 Total contributions made in 2024 $ Form 5498-SA TRUSTEE’S TIN PARTICIPANT’S TIN 3 Total HSA or Archer MSA contributions made in 2025 for 2024 Copy B $ PARTICIPANT’S name 4 Rollover contributions 5 Fair market value of HSA, Archer MSA, or MA MSA For Participant $ $ Street address (including apt. no.) 6 HSA Archer MSA City or town, state or province, country, and ZIP or foreign postal code This information MA MSA is being furnished to the IRS. Account number (see instructions) Form 5498-SA (keep for your records) www.irs.gov/Form5498SA Department of the Treasury - Internal Revenue Service |
Enlarge image | 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 2024 and through account (HSA), Archer medical savings account (MSA), or Medicare Advantage April 15, 2025, for 2024. You may be able to deduct this amount on your 2024 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 2024 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 2025 for contribution to your Archer MSA if your spouse is covered under a high 2024. 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 2024 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 makes 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 2024. 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. |