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Attention:

Do not download, print, and file Copy A with the IRS.


Copy A appears in red, similar to the official IRS form,
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that cannot be scanned.
You may order these forms online at Forms and Publications
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See IRS Publications 1141, 1167, 1179, and other IRS
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TLS, have you I.R.S. SPECIFICATIONS TO BE REMOVED BEFORE PRINTING Action Date Signature
transmitted all R
text files for this INSTRUCTIONS TO PRINTERS O.K. to print
cycle update? FORM 5498-SA, PAGE 1 OF 6 (Page 2 is blank)
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD T:FP:F
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11") O.K. to print
Date PERFORATE: None Responsible
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Revised proofs
requested

INK: Red, J-6983 Separation for 2000 Form 5498-SA Page 1


INK: Black Separation for 2000 Form 5498-SA Page 1

2727 VOID CORRECTED


TRUSTEE’S name, street address, city, state, and ZIP code 1 Employee or self-employed person’s OMB No. 1545-1518
Archer MSA contributions made in HSA, Archer MSA, or
2006 and 2007 for 2006 Medicare Advantage
$
2 Total contributions made
in 2006
2006 MSA Information

$ Form 5498-SA
TRUSTEE’S federal identification number PARTICIPANT’S social security number 3 Total HSA or Archer MSA contributions made in 2007 for 2006
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.)
For Privacy Act
6 HSA
and Paperwork
Archer Reduction Act
MSA
City, state, and ZIP code Notice, see the
MA 2006 General
MSA
Instructions for
Account number (see instructions) Forms 1099, 1098,
5498, and W-2G.

Form 5498-SA Cat. No. 38467V 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
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I.R.S. SPECIFICATIONS TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 5498-SA, PAGE 3 OF 6
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None
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CORRECTED (if checked)


TRUSTEE’S name, street address, city, state, and ZIP code 1 Employee or self-employed person’s OMB No. 1545-1518
Archer MSA contributions made in HSA, Archer MSA, or
2006 and 2007 for 2006 Medicare Advantage
$
2 Total contributions made
in 2006
2006 MSA Information

$ Form 5498-SA
TRUSTEE’S federal identification number PARTICIPANT’S social security number 3 Total HSA or Archer MSA contributions made in 2007 for 2006
$ 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 The information
Archer in boxes 1 through
MSA 6 is being
City, state, and ZIP code
MA furnished to the
MSA Internal Revenue
Account number (see instructions) Service.

Form 5498-SA (keep for your records) Department of the Treasury - Internal Revenue Service
3
I.R.S. SPECIFICATIONS TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 5498-SA, PAGE 4 OF 6
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Instructions to Participant
This information is submitted to the Internal Revenue Service by the Box 1. Shows employee or self-employed person’s Archer MSA
trustee of your health savings account (HSA), Archer MSA, or Medicare contributions made to your Archer MSA in 2006 and through April 16,
Advantage MSA (MA MSA). 2007, for 2006. You may be able to deduct this amount on your 2006
Generally, contributions you make to your HSA or Archer MSA are Form 1040. See the Form 1040 instructions.
deductible. However, employer contributions to your HSA are not Note. The information in boxes 2 and 3 is provided by the trustee for IRS
deductible. If your employer makes a contribution to one of your Archer use only.
MSAs, you cannot contribute to any Archer MSA for that year. If you Box 2. Shows the total employer and employee/self-employed
made a contribution to your Archer MSA when your employer has contributions made in 2006 to your HSA or Archer MSA. The trustee of
contributed, you cannot deduct your contribution, and you will have an your MA MSA is not required to, but may, show contributions to your
excess contribution. If your spouse’s employer makes a contribution to MA MSA.
your spouse’s Archer MSA, you cannot make a contribution to your
Archer MSA if your spouse is covered under a high deductible health Box 3. Shows the total HSA or Archer MSA contributions made in 2007
plan that also covers you. for 2006.
Contributions that the Social Security Administration makes to your Box 4. Shows any rollover contribution you made to this Archer MSA in
MA MSA are not includible in your gross income nor are they deductible. 2006 after a distribution from another Archer MSA or shows any rollover
Neither you nor your employer can make contributions to your MA MSA. to this HSA from another HSA or Archer MSA. See Form 8853 or Form
8889 and their instructions for information about how to report
See Form 8853, Archer MSAs and Long-Term Care Insurance Contracts,
distributions and rollovers. This amount is not included in box 1, 2, or 3.
and its instructions or Form 8889, Health Savings Accounts (HSAs) and its
instructions. Any employer contributions made to an Archer MSA are shown Box 5. Shows the fair market value of your HSA, Archer MSA, or MA
on your Form W-2 in Box 12 (code R); employer contributions made to MSA at the end of 2006.
HSAs are shown in Box 12 (code W). Box 6. Shows the type of account that is reported on this Form 5498-SA.
For more information, see Pub. 969, Health Savings Accounts and Other Other information. The trustee of your HSA, Archer MSA, or MA MSA
Tax-Favored Health Plans. may provide other information about your account on this form.
Account number. May show an account or other unique number the Note. Do not attach Form 5498-SA to your income tax return. Instead,
trustee assigned to distinguish your account. keep it for your records.
3
I.R.S. SPECIFICATIONS TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 5498-SA, PAGE 5 OF 6
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

VOID CORRECTED
TRUSTEE’S name, street address, city, state, and ZIP code 1 Employee or self-employed person’s OMB No. 1545-1518
Archer MSA contributions made in HSA, Archer MSA, or
2006 and 2007 for 2006 Medicare Advantage
$
2 Total contributions made
in 2006
2006 MSA Information

$ Form 5498-SA
TRUSTEE’S federal identification number PARTICIPANT’S social security number 3 Total HSA or Archer MSA contributions made in 2007 for 2006
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
$ $
Reduction Act
Street address (including apt. no.) 6 HSA Notice, see the
Archer
MSA
2006 General
City, state, and ZIP code
MA
Instructions for
MSA Forms 1099,
Account number (see instructions) 1098, 5498,
and W-2G.

Form 5498-SA Department of the Treasury - Internal Revenue Service


3
I.R.S. SPECIFICATIONS TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 5498-SA, PAGE 6 OF 6
MARGINS; TOP 13mm (1/2"), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8-1/2") x 279mm (11")
PERFORATE: None
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Instructions for Trustees


General and specific form instructions are Caution: Because paper for ms are scanned
provided as separate products. The products dur ing processing, you cannot file For ms
you should use to complete Form 5498-SA 1096, 1098, 1099, or 5498 that you download
are the 2006 General Instructions for Forms and pr int from the IRS website.
1099, 1098, 5498, and W-2G, and the 2006 Due dates. Furnish Copy B of this form to
Instructions for Forms 1099-SA and 5498-SA. the participant by May 31, 2007.
A chart in the general instructions gives a File Copy A of this form with the IRS by
quick guide to which form must be filed to May 31, 2007. To file electronically, you must
report a particular payment. To order these have software that generates a file according
instructions and additional forms, call to the specifications in Pub. 1220,
1-800-TAX-FORM (1-800-829-3676). Specifications for Filing Forms 1098, 1099,
5498, and W-2G Electronically or
Magnetically. IRS does not provide a fill-in
form option.

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