Get IRS 5498-SA 2021

Future developments. For the latest information about developments related to published go to www.irs.gov/form5498sa. Copy C For Trustee Certain To complete Form 5498-SA use Returns and The 2017 Instructions for Forms 1099-SA and 5498-SA. This amount isn t included in box 1 2 or 3. Box 5. Shows the fair market value of your HSA Archer MSA or MA MSA at the end of 2017. Other information. The trustee of your HSA Archer MSA or MA MSA may provide other information about your account on this form. Note Don t attach Form 5498-SA to your income tax return. Instead keep it for your records. 1220. developments related to Form 5498-SA and its instructions such as legislation enacted after they were Need help If you have questions about reporting on service site toll free at 1-866-455-7438 or 304-263-8700 not toll free. VOID CORRECTED TRUSTEE S name street address city or town state or province country ZIP or foreign postal code and telephone number 1 Employee or self-employed person s Archer MSA contributions made in 2017 and 2018 for 2017 OMB No. 1545-1518 2 Total contributions made in 2017 Form 5498-SA TRUSTEE S federal identification number PARTICIPANT S social security number HSA Archer MSA or Medicare Advantage MSA Information 3 Total HSA or Archer MSA contributions made in 2018 for 2017 PARTICIPANT S name 4 Rollover contributions 5 Fair market value of HSA Archer MSA or MA MSA 6 HSA Street address including apt. no. Archer MSA City or town state or province country and ZIP or foreign postal code MA MSA Account number see instructions Cat. No. 38467V www.irs.gov/form5498sa Copy A For Internal Revenue Service Center File with Form 1096. For Privacy Act and Paperwork Reduction Act Notice see the 2017 General Instructions for Certain Information Returns. 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 CORRECTED if checked Participant Copy B keep for your records This information is being furnished to the Internal Revenue Service. account HSA Archer medical savings account MSA or Medicare Advantage MSA MA MSA. Generally contributions you make to your Archer MSA are deductible. Employer contributions are excluded from your income and aren t deductible by you. If your employer makes a contribution to one of your Archer MSAs you can t contribute to any Archer MSA for that year. If you made a contribution to your Archer MSA when your employer has contributed you can t deduct your employer makes a contribution to your spouse s Archer MSA you can t make a contribution to your Archer MSA if your spouse is covered under a high deductible health plan that also covers you. Contributions that the Social Security Administration makes to your MA MSA aren t includible in your gross income nor are they deductible. Neither you nor your employer can make contributions to your MA MSA. your HSA are deductible on your tax return* Employer contributions to your HSA may be excluded from your income and aren t deductible by you.