IRS Form 5498-SA 2019 Hsa, Archer Msa, or Medicare Advantage Msa Information

What Is Form 5498-SA?

IRS Form 5498-SA, HSA, Archer MSA, or Medicare Advantage MSA Information is a form filed with the Internal Revenue Service (IRS) by a trustee or custodian of a Health Savings Account (HSA), Medicare Advantage MSA (MA MSA), or Archer Medical Savings Account (Archer MSA). Trustees or custodians are required to file a separate form for each type of plan and for each person for whom they maintained one of these savings accounts.

This form is issued by the IRS and it is revised annually. Use the 2020 version when filing your 2019 taxes.

Where to Get Form 5498-SA?

Download a fillable IRS Form 5498-SA through the link below or through the IRS official website.

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CORRECTED
2727
TRUSTEE’S name, street address, city or town, state or province, country,
1 Employee or self-employed
OMB No. 1545-1518
ZIP or foreign postal code, and telephone number
person’s Archer MSA
HSA, Archer MSA, or
contributions made in 2019
2019
and 2020 for 2019
Medicare Advantage
$
MSA Information
2 Total contributions made in 2019
5498-SA
$
Form
Copy A
TRUSTEE’S TIN
PARTICIPANT'S TIN
3 Total HSA or Archer MSA contributions made in 2020 for 2019
$
For
Internal Revenue
PARTICIPANT'S name
4 Rollover contributions
5 Fair market value of HSA,
Service Center
Archer MSA, or MA MSA
$
$
File with Form 1096.
For Privacy Act and
Street address (including apt. no.)
6 HSA
Paperwork
Archer MSA
Reduction Act
Notice, see
City or town, state or province, country, and ZIP or foreign postal code
MA
MSA
the 2019 General
Instructions for
Account number (see instructions)
Certain Information
Returns.
5498-SA
Form
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
VOID
CORRECTED
2727
TRUSTEE’S name, street address, city or town, state or province, country,
1 Employee or self-employed
OMB No. 1545-1518
ZIP or foreign postal code, and telephone number
person’s Archer MSA
HSA, Archer MSA, or
contributions made in 2019
2019
and 2020 for 2019
Medicare Advantage
$
MSA Information
2 Total contributions made in 2019
5498-SA
$
Form
Copy A
TRUSTEE’S TIN
PARTICIPANT'S TIN
3 Total HSA or Archer MSA contributions made in 2020 for 2019
$
For
Internal Revenue
PARTICIPANT'S name
4 Rollover contributions
5 Fair market value of HSA,
Service Center
Archer MSA, or MA MSA
$
$
File with Form 1096.
For Privacy Act and
Street address (including apt. no.)
6 HSA
Paperwork
Archer MSA
Reduction Act
Notice, see
City or town, state or province, country, and ZIP or foreign postal code
MA
MSA
the 2019 General
Instructions for
Account number (see instructions)
Certain Information
Returns.
5498-SA
Form
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
CORRECTED (if checked)
TRUSTEE’S name, street address, city or town, state or province, country,
1 Employee or self-employed
OMB No. 1545-1518
ZIP or foreign postal code, and telephone number
person’s Archer MSA
HSA, Archer MSA, or
contributions made in 2019
2019
and 2020 for 2019
Medicare Advantage
$
MSA Information
2 Total contributions made in 2019
5498-SA
$
Form
TRUSTEE’S TIN
PARTICIPANT'S TIN
3 Total HSA or Archer MSA contributions made in 2020 for 2019
Copy B
$
PARTICIPANT'S name
4 Rollover contributions
5 Fair market value of HSA,
For
Archer MSA, or MA MSA
Participant
$
$
Street address (including apt. no.)
6 HSA
Archer MSA
This information
City or town, state or province, country, and ZIP or foreign postal code
MA
is being furnished
MSA
to the IRS.
Account number (see instructions)
5498-SA
Form
(keep for your records)
www.irs.gov/Form5498SA
Department of the Treasury - Internal Revenue Service
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 2019 and through
account (HSA), Archer medical savings account (MSA), or Medicare Advantage
April 15, 2020, for 2019. You may be able to deduct this amount on your 2019
MSA (MA MSA).
Form 1040. See the Form 1040 instructions.
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 2019 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 2020 for
contribution to your Archer MSA if your spouse is covered under a high
2019.
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 2019 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 2019.
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.
Other information. The trustee of your HSA, Archer MSA, or MA MSA may
See Form 8853 and its instructions or Form 8889 and its instructions. Any
provide other information about your account on this form.
employer contributions made to an Archer MSA are shown on your Form W-2 in
Note: Don't attach Form 5498-SA to your income tax return. Instead, keep it for
box 12 (code R); employer contributions made to an HSA are shown in box 12
your records.
(code W). For more information, see Pub. 969.
Future developments. For the latest information about developments related to
Participant's taxpayer identification number (TIN). For your protection, this
Form 5498-SA and its instructions, such as legislation enacted after they were
form may show only the last four digits of your social security number (SSN),
published, go to www.irs.gov/Form5498SA.
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.
VOID
CORRECTED
1 Employee or self-employed
OMB No. 1545-1518
TRUSTEE’S name, street address, city or town, state or province, country,
person’s Archer MSA
ZIP or foreign postal code, and telephone number
HSA, Archer MSA, or
contributions made in 2019
2019
and 2020 for 2019
Medicare Advantage
$
MSA Information
2 Total contributions made in 2019
5498-SA
$
Form
Copy C
TRUSTEE’S TIN
PARTICIPANT'S TIN
3 Total HSA or Archer MSA contributions made in 2020 for 2019
$
For Trustee
PARTICIPANT'S name
4 Rollover contributions
5 Fair market value of HSA,
Archer MSA, or MA MSA
For Privacy Act
and Paperwork
$
$
Reduction Act
Street address (including apt. no.)
6 HSA
Notice, see the
Archer MSA
2019 General
City or town, state or province, country, and ZIP or foreign postal code
MA
Instructions for
MSA
Certain
Information
Account number (see instructions)
Returns.
5498-SA
Form
www.irs.gov/Form5498SA
Department of the Treasury - Internal Revenue Service
Instructions for Trustee
generates a file according to the specifications in Pub.
To complete Form 5498-SA, use:
1220.
• The 2019 General Instructions for Certain Information
Future developments. For the latest information about
Returns, and
developments related to Form 5498-SA and its
• The 2019 Instructions for Forms 1099-SA and
instructions, such as legislation enacted after they were
5498-SA.
published, go to www.irs.gov/Form5498SA.
To get and to order these instructions, go to
Need help? If you have questions about reporting on
www.irs.gov/Form5498SA.
Form 5498-SA, call the information reporting customer
Due dates. Furnish Copy B of this form to the
service site toll free at 866-455-7438 or 304-263-8700
(not toll free). Persons with a hearing or speech
participant by June 1, 2020.
disability with access to TTY/TDD equipment can call
File Copy A of this form with the IRS by June 1, 2020.
304-579-4827 (not toll free).
To file electronically, you must have software that

Download IRS Form 5498-SA 2019 Hsa, Archer Msa, or Medicare Advantage Msa Information

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What Is the Purpose of Form 5498-SA?

The purpose of the form is to report amounts contributed (including transfers and rollovers), as well as the fair market value (FMV) of accounts for the calendar year.

IRS Form 5498-SA Instructions

The current edition of Form 5498-SA due date is June 1, 2020. If you do not timely file Copy A of this form, a penalty of $50 per return shall be applied (if the failure is not justified by reasonable cause). However, if the due date is a holiday, Saturday or Sunday, you may file this return the next business day. It is possible to request a 30-day extension for filing by completing Form 8809 and sending it on paper before the due date.

Copy B of this form must be furnished to the participant by June 1, 2020. You may also request an extension to furnish Copy B by sending a letter to the following address: Internal Revenue Service

Attn: Extension of Time Coordinator, 240 Murall Drive, Mail Stop 4360, Kearneysville, WV 25430.

Although it is not mandatory, you may provide the participant with a statement of December 31, 2019, FMV of their account by January 31, 2020.

If you are filing less than 250 forms on paper, you may send a black-and-white Copy A of the 5498-SA together with Form 1096, Annual Summary and Transmittal of U.S. Information Returns. If you are required to send more than 250 forms, you must file electronically through the Filing Information Returns Electronically System (FIRE System).

Form 1099-SA and Form 5498-SA are both related to health savings accounts. The purpose of Form 1099-SA is reporting distributions to an account, while Form 5498-SA is for reporting contributions to an account.

IRS 5498-SA Related Forms

The form is part of the IRS 5498 form series. The other three related forms within this group are briefly described below:

  • IRS Form 5498, IRA Contribution Information, is a form that financial institutions acting as trustees or issuers of IRAs file with the IRS every year for each person for whom they maintained any IRA, with the purpose of reporting contributions made to these plans and other relevant information.
  • IRS Form 5498-ESA, Coverdell ESA Contribution Information, is a form filed with the IRS by a trustee or issuer of a Coverdell education savings account (ESA) for each person for whom they maintained any ESA, with the purpose of reporting amounts of contributions to a Coverdell ESA and other relevant information.
  • IRS Form 5498-QA, ABLE Account Contribution Information, is a form filed with the IRS by any State or its agency or instrumentality with the purpose of reporting the contributions made to an ABLE account for each qualified ABLE account they established and maintained.
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