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OMB No. 1545-1518

Form 5498-SA
2024
HSA, Archer MSA, or Medicare Advantage MSA Information

Copy A For Internal Revenue Service Center

File with Form 1096.

For Privacy Act and Paperwork Reduction Act Notice, see the 2024 General Instructions for Certain Information Returns.

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 $ ----
6 
-- HSA
-- Archer MSA
-- MA MSA

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

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-- CORRECTED (if checked)
OMB No. 1545-1518

Form 5498-SA
2024
HSA, Archer MSA, or Medicare Advantage MSA Information

Copy B For Participant

This information is being furnished to the IRS.

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 $ ----
6 
-- HSA
-- Archer MSA
-- MA MSA

Form 5498-SA 
(keep for your records)
www.irs.gov/Form5498SA
Department of the Treasury - Internal Revenue Service

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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 makes 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 2024 and through April 15, 2025, for 2024. You may be able to deduct this amount on your 2024 Form 1040 or 1040-SR. See the Instructions for Form 1040.

Note: The information in boxes 2 and 3 is provided for IRS use only.

Box 2. Shows the total contributions made in 2024 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 2025 for 2024.

Box 4. Shows any rollover contribution from an Archer MSA to this Archer MSA in 2024 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 2024.

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.

Free File Program. Go to www.irs.gov/FreeFile to see if you qualify for no-cost online federal tax preparation, e-filing, and direct deposit or payment options.
