Form 5498-SA — HSA, Archer MSA, or Medicare Advantage MSA

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f5498sa.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

Copy A

For Internal Revenue

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2727 VOID CORREC					CTED
TRUSTEE’S name	TRUSTEE’S name	TRUSTEE’S name	TRUSTEE’S name	TRUSTEE’S name	1 Employee’s or self- employed person’s Archer MSA contributions made in the calendar year and the subsequent year for the calendar year $	Form5498-SA (Rev. December 2026) OMB No. 1545-1518
Street address	Street address	Street address	Street address	Room/suite no.	Room/suite no.	Room/suite no.
City/town	State/province	State/province	Country	ZIP/foreign code	ZIP/foreign code	For calendar year
Telephone number:	Telephone number:	Telephone number:	Telephone number:	Telephone number:	2 Total contributions made in the calendar year $	2 Total contributions made in the calendar year $
TRUSTEE’S TIN	TRUSTEE’S TIN	PARTICIPANT’S TIN	PARTICIPANT’S TIN	PARTICIPANT’S TIN	PARTICIPANT’S TIN	PARTICIPANT’S TIN
TRUSTEE’S TIN	TRUSTEE’S TIN	PARTICIPANT’S TIN	PARTICIPANT’S TIN	PARTICIPANT’S TIN	3 Total HSA or Archer MSA contributions made in the subsequent year for the calendar year $	3 Total HSA or Archer MSA contributions made in the subsequent year for the calendar year $
PARTICIPANT’S name	PARTICIPANT’S name	PARTICIPANT’S name	PARTICIPANT’S name	PARTICIPANT’S name	PARTICIPANT’S name	PARTICIPANT’S name
Street address	Street address	Street address	Street address	Apt. no.	4 Rollover contributions $	5 Fair market value of HSA, Archer MSA, or MA MSA $
City/town	State/province	State/province	Country	ZIP/foreign code	ZIP/foreign code	ZIP/foreign code
City/town	State/province	State/province	Country	ZIP/foreign code	6 HSA Archer MSA MA MSA
Account number (see instructions)	Account number (see instructions)	Account number (see instructions)	Account number (see instructions)	Account number (see instructions)	Account number (see instructions)	Account number (see instructions)

Form 5498-SA (Rev. 12-2026) Created 9/18/25 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

Cat. No. 38467V

Department of the Treasury - Internal Revenue Service

CORRECTED (if checked)

Copy B

For Participant

This information is being furnished

to the IRS.

TRUSTEE’S name					1 Employee’s or self- employed person’s Archer MSA contributions made in the calendar year and the subsequent year for the calendar year $	OMB No. 1545-1518 5498-SA Form (Rev. December 2026)
Street address	Street address	Street address	Street address	Room/suite no.	Room/suite no.	Room/suite no.
City/town	State/province	State/province	Country	ZIP/foreign code	ZIP/foreign code	For calendar year
Telephone number:	Telephone number:	Telephone number:	Telephone number:	Telephone number:	2 Total contributions made in the calendar year $	2 Total contributions made in the calendar year $
TRUSTEE’S TIN	TRUSTEE’S TIN	PARTICIPANT’S TIN	PARTICIPANT’S TIN	PARTICIPANT’S TIN	PARTICIPANT’S TIN	PARTICIPANT’S TIN
TRUSTEE’S TIN	TRUSTEE’S TIN	PARTICIPANT’S TIN	PARTICIPANT’S TIN	PARTICIPANT’S TIN	3 Total HSA or Archer MSA contributions made in the subsequent year for the calendar year $	3 Total HSA or Archer MSA contributions made in the subsequent year for the calendar year $
PARTICIPANT’S name	PARTICIPANT’S name	PARTICIPANT’S name	PARTICIPANT’S name	PARTICIPANT’S name	PARTICIPANT’S name	PARTICIPANT’S name
Street address	Street address	Street address	Street address	Apt. no.	4 Rollover contributions $	5 Fair market value of HSA, Archer MSA, or MA MSA $
City/town	State/province	State/province	Country	ZIP/foreign code	ZIP/foreign code	ZIP/foreign code
City/town	State/province	State/province	Country	ZIP/foreign code	6 HSA Archer MSA MA MSA
Account number (see instructions)	Account number (see instructions)	Account number (see instructions)	Account number (see instructions)	Account number (see instructions)	Account number (see instructions)	Account number (see instructions)

Form 5498-SA (Rev. 12-2026) (keep for your records) www.irs.gov/Form5498SA

Department of the Treasury - Internal Revenue Service

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 in the calendar year and through April 15 of the subsequent year to your Archer MSA. You may be able to deduct this amount on your 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 to your HSA or Archer MSA in the calendar year shown on this form. 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 the subsequent year for the calendar year shown on this form. Box 4. Shows any rollover contribution from an Archer MSA to this Archer MSA in the calendar year shown on this form 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 the calendar year shown on this form. 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.