2727                  VOID              CORRECTED
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 
                                                                            contributions made in 2023                       HSA, Archer MSA, or 
                                                                            and 2024 for 2023
                                                                                                                             Medicare Advantage 
                                                                          $                                   2023
                                                                                                                                        MSA Information
                                                                          2 Total contributions made in 2023
                                                                          $                                 Form 5498-SA
TRUSTEE’S TIN                       PARTICIPANT’S TIN                     3 Total HSA or Archer MSA contributions made in 2024 for 2023     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 2023 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

                                                            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 
                                                                            contributions made in 2023                       HSA, Archer MSA, or 
                                                                            and 2024 for 2023
                                                                                                                             Medicare Advantage 
                                                                          $                                   2023
                                                                                                                                        MSA Information
                                                                          2 Total contributions made in 2023
                                                                          $                                 Form 5498-SA
TRUSTEE’S TIN                       PARTICIPANT’S TIN                     3 Total HSA or Archer MSA contributions made in 2024 for 2023
                                                                                                                                        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

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.

                                              VOID           CORRECTED
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 
                                                                            contributions made in 2023                       HSA, Archer MSA, or 
                                                                            and 2024 for 2023
                                                                                                                             Medicare Advantage 
                                                                          $                                   2023
                                                                                                                                        MSA Information
                                                                          2 Total contributions made in 2023
                                                                          $                                 Form 5498-SA
TRUSTEE’S TIN                       PARTICIPANT’S TIN                     3 Total HSA or Archer MSA contributions made in 2024 for 2023 Copy C
                                                                          $                                                             For Trustee
PARTICIPANT’S name                                                        4 Rollover contributions          5 Fair market value of HSA, 
                                                                                                              Archer MSA, or MA MSA
                                                                                                                                        For Privacy Act 
                                                                          $                                 $                           and Paperwork 
Street address (including apt. no.)                                       6 HSA                                                         Reduction Act 
                                                                                                                                        Notice, see the 
                                                                          Archer MSA                                                    2023 General 
City or town, state or province, country, and ZIP or foreign postal code                                                                Instructions for 
                                                                          MA MSA
                                                                                                                                        Certain 
Account number (see instructions)                                                                                                       Information 
                                                                                                                                        Returns.
Form 5498-SA                                      www.irs.gov/Form5498SA                                      Department of the Treasury - Internal Revenue Service

Instructions for Trustee
To complete Form 5498-SA, use:                          Filing and furnishing. For filing and furnishing 
                                                        instructions, including due dates, and to request filing or 
• The 2023 General Instructions for Certain Information furnishing extensions, see the 2023 General Instructions 
Returns, and                                            for Certain Information Returns.
• The 2023 Instructions for Forms 1099-SA and           Need help? If you have questions about reporting on 
5498-SA.                                                Form 5498-SA, call the Technical Services Operations 
  To get and to order these instructions, go to         (TSO) toll free at 866-455-7438 or 304-263-8700 (not 
www.irs.gov/EmployerForms.                              toll free). 
Caution: Because paper forms are scanned during 
processing, you cannot file certain Forms 1096, 1097, 
1098, 1099, 3921, or 5498 that you print from the IRS 
website.