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Federal Free Printable 2019 Form 5498-SA for 2019 Federal HSA, Archer MSA, or Medicare Advantage MSA Information

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HSA, Archer MSA, or Medicare Advantage MSA Information
2019 Form 5498-SA

2727 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 2019 and 2020 for 2019 OMB No. 1545-1518 2019 $ 2 Total contributions made in 2019 Form 5498-SA $ TRUSTEE’S TIN PARTICIPANT'S TIN HSA, Archer MSA, or Medicare Advantage MSA Information 3 Total HSA or Archer MSA contributions made in 2020 for 2019 $ 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) Form 5498-SA 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 2019 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) 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 2019 and 2020 for 2019 OMB No. 1545-1518 2019 $ 2 Total contributions made in 2019 Form 5498-SA $ TRUSTEE’S TIN PARTICIPANT'S TIN HSA, Archer MSA, or Medicare Advantage MSA Information 3 Total HSA or Archer MSA contributions made in 2020 for 2019 $ PARTICIPANT'S name 4 Rollover contributions 5 Fair market value of HSA, Archer MSA, or MA MSA $ $ Copy B For Participant 6 HSA Street address (including apt. no.) Archer MSA City or town, state or province, country, and ZIP or foreign postal code MA MSA This information 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 Instructions for Participant This information is submitted to the IRS by the trustee of your health savings 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 contribution, and you will have an excess contribution. If your spouse’s 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. Generally, contributions you or someone other than your employer make to 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. You and your employer can make contributions to your HSA in the same year. See Form 8853 and its instructions or Form 8889 and its instructions. Any employer contributions made to an Archer MSA are shown on your Form W-2 in box 12 (code R); employer contributions made to an HSA are shown in box 12 (code W). For more information, see Pub. 969. Participant's taxpayer identification number (TIN). For your protection, this form may show only the last four digits of your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN). However, the issuer has reported your complete TIN to the IRS. Account number. May show an account or other unique number the trustee assigned to distinguish your account. Box 1. Shows contributions you made to your Archer MSA in 2019 and through April 15, 2020, for 2019. You may be able to deduct this amount on your 2019 Form 1040. See the Form 1040 instructions. Note: The information in boxes 2 and 3 is provided for IRS use only. Box 2. Shows the total contributions made in 2019 to your HSA or Archer MSA. See Pub. 969 for who can make contributions. This includes qualified HSA funding distributions (trustee-to-trustee transfers) from your IRA to fund your HSA. The trustee of your MA MSA isn't required to, but may, show contributions to your MA MSA. Box 3. Shows the total HSA or Archer MSA contributions made in 2020 for 2019. Box 4. Shows any rollover contribution from an Archer MSA to this Archer MSA in 2019 or any rollover from an HSA or Archer MSA to this HSA. See Form 8853 or Form 8889 and their instructions for information about how to report distributions. 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 2019. Box 6. Shows the type of account that is reported on this Form 5498-SA. 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. Future developments. For the latest information about developments related to Form 5498-SA and its instructions, such as legislation enacted after they were published, go to www.irs.gov/Form5498SA. 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 2019 and 2020 for 2019 OMB No. 1545-1518 2019 $ 2 Total contributions made in 2019 Form 5498-SA $ TRUSTEE’S TIN PARTICIPANT'S TIN HSA, Archer MSA, or Medicare Advantage MSA Information 3 Total HSA or Archer MSA contributions made in 2020 for 2019 $ 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 Account number (see instructions) Form 5498-SA www.irs.gov/Form5498SA MA MSA Copy C For Trustee For Privacy Act and Paperwork Reduction Act Notice, see the 2019 General Instructions for Certain Information Returns. Department of the Treasury - Internal Revenue Service Instructions for Trustee To complete Form 5498-SA, use: • The 2019 General Instructions for Certain Information Returns, and • The 2019 Instructions for Forms 1099-SA and 5498-SA. To get and to order these instructions, go to www.irs.gov/Form5498SA. Due dates. Furnish Copy B of this form to the participant by June 1, 2020. File Copy A of this form with the IRS by June 1, 2020. To file electronically, you must have software that generates a file according to the specifications in Pub. 1220. Future developments. For the latest information about developments related to Form 5498-SA and its instructions, such as legislation enacted after they were published, go to www.irs.gov/Form5498SA. Need help? If you have questions about reporting on Form 5498-SA, call the information reporting customer service site toll free at 866-455-7438 or 304-263-8700 (not toll free). Persons with a hearing or speech disability with access to TTY/TDD equipment can call 304-579-4827 (not toll free).
Extracted from PDF file 2019-federal-form-5498-sa.pdf, last modified November 2018

More about the Federal Form 5498-SA Other TY 2019

We last updated the HSA, Archer MSA, or Medicare Advantage MSA Information in February 2019, so this is the latest version of Form 5498-SA, fully updated for tax year 2018. You can download or print current or past-year PDFs of Form 5498-SA directly from TaxFormFinder. You can print other Federal tax forms here.

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Form Sources:

The Internal Revenue Service usually releases income tax forms for the current tax year between October and January, although changes to some forms can come even later. We last updated Federal Form 5498-SA from the Internal Revenue Service in February 2019.

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Historical Past-Year Versions of Federal Form 5498-SA

We have a total of eight past-year versions of Form 5498-SA in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:


2019 Form 5498-SA

2019 Form 5498-SA

2017 Form 5498-SA

2018 Form 5498-SA

2016 Form 5498-SA

2017 Form 5498-SA

HSA, Archer MSA, or Medicare Advantage MSA Information 2015 Form 5498-SA

2016 Form 5498-SA

HSA, Archer MSA, or Medicare Advantage MSA Information 2014 Form 5498-SA

2014 Form 5498-SA

HSA, Archer MSA, or Medicare Advantage MSA Information 2013 Form 5498-SA

2013 Form 5498-SA

HSA, Archer MSA, or Medicare Advantage MSA Information 2012 Form 5498-SA

2012 Form 5498-SA

HSA, Archer MSA, or Medicare Advantage MSA Information 2011 Form 5498-SA

2012 Form 5498-SA


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