HSA, Archer MSA, or Medicare Advantage MSA Information Revision Date 11/02/2022

• Legal Form Number: 5498-SA
• Year: 2025
• Issuer: Treasury Department
• Section: Treasury Department

Form 5498-SA

Cat. No. 38467V

HSA, Archer MSA, or

Medicare Advantage

MSA Information

Copy A

For

Internal Revenue

Service Center

Department of the Treasury - Internal Revenue Service

File with Form 1096.

OMB No. 1545-1518

For Privacy Act and

Paperwork

Reduction Act

Notice, see

the 2024 General

Instructions for

Certain Information

Returns.

2727 VOID CORRECTED

TRUSTEE’S name, street address, city or town, state or province, country,

ZIP or foreign postal code, and telephone number

TRUSTEE’S TIN PARTICIPANT’S TIN

PARTICIPANT’S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

Account number (see instructions)

1 Employee’s or self-

employed person’s Archer

MSA contributions made in

2024 and 2025 for 2024

$

2

Total contributions made in 2024

$

3

Total HSA or Archer MSA contributions made in 2025 for 2024

$

4 Rollover contributions

$

5 Fair market value of HSA,

Archer MSA, or MA MSA

$

6HSA

Archer MSA

MA MSA

2024

Form 5498-SA www.irs.gov/Form5498SA

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