Exhibit W
Internal Revenue Bulletin 2003-16 · 2026-10-03 edition · updated 2026-10-04 · United States
Archer MSA or
Copy A
For Internal Revenue
Service Center
File with Form 1096.
For Privacy Act
and Paperwork
Reduction Act Notice, see the
2003 General Instructions for Forms 1099, 1098,
5498, and W-2G.
| TRUSTEE’S name, street address, city, state, and ZIP code | 1Employee or self-employed person’s Archer MSA contributions made in 2003 and 2004 for 2003 $ |
OMB No. 1545-1518 2003 Form 5498-MSA |
|
|---|---|---|---|
| TRUSTEE’S name, street address, city, state, and ZIP code | TRUSTEE’S name, street address, city, state, and ZIP code | 1.40" Total contributions made in 2003 2 $ |
1.40" Total contributions made in 2003 2 $ |
| TRUSTEE’S Federal identification number | PARTICIPANT’S social security number | Total Archer MSA contributions made in 2004 for 2003 3 $ |
Total Archer MSA contributions made in 2004 for 2003 3 $ |
3.40" PARTICIPANT’S name |
3.40" PARTICIPANT’S name |
Rollover contributions 4 $ |
Fair market value of Archer MSA or M+C MSA 5 $ |
| Street address (including apt. no.) | Street address (including apt. no.) | Medicare+Choice MSA 6 |
|
| City, state, and ZIP code | City, state, and ZIP code | ||
| Account number (optional) | Account number (optional) | Account number (optional) | Account number (optional) |
Form 5498-MSA Cat. No. 23097L 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
Archer MSA or
Copy A
For Internal Revenue
Service Center
File with Form 1096.
For Privacy Act
and Paperwork
Reduction Act Notice, see the
2003 General Instructions for Forms 1099, 1098,
5498, and W-2G.
| TRUSTEE’S name, street address, city, state, and ZIP code | 1Employee or self-employed person’s Archer MSA contributions made in 2003 and 2004 for 2003 $ |
OMB No. 1545-1518 2003 Form 5498-MSA |
|
|---|---|---|---|
| TRUSTEE’S name, street address, city, state, and ZIP code | TRUSTEE’S name, street address, city, state, and ZIP code | Total contributions made in 2003 2 $ |
Total contributions made in 2003 2 $ |
| TRUSTEE’S Federal identification number | PARTICIPANT’S social security number | Total Archer MSA contributions made in 2004 for 2003 3 $ |
Total Archer MSA contributions made in 2004 for 2003 3 $ |
| PARTICIPANT’S name | PARTICIPANT’S name | Rollover contributions 4 $ |
Fair market value of Archer MSA or M+C MSA 5 $ |
| Street address (including apt. no.) | Street address (including apt. no.) | Medicare+Choice MSA 6 |
|
| City, state, and ZIP code | City, state, and ZIP code | ||
| Account number (optional) | Account number (optional) | Account number (optional) | Account number (optional) |
Form 5498-MSA Cat. No. 23097L 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
Archer MSA or
Copy A
For Internal Revenue
Service Center
File with Form 1096.
For Privacy Act
and Paperwork
Reduction Act Notice, see the
2003 General Instructions for Forms 1099, 1098,
5498, and W-2G.
| TRUSTEE’S name, street address, city, state, and ZIP code | 1Employee or self-employed person’s Archer MSA contributions made in 2003 and 2004 for 2003 $ |
OMB No. 1545-1518 2003 Form 5498-MSA |
|
|---|---|---|---|
| TRUSTEE’S name, street address, city, state, and ZIP code | TRUSTEE’S name, street address, city, state, and ZIP code | Total contributions made in 2003 2 $ |
Total contributions made in 2003 2 $ |
| TRUSTEE’S Federal identification number | PARTICIPANT’S social security number | Total Archer MSA contributions made in 2004 for 2003 3 $ |
Total Archer MSA contributions made in 2004 for 2003 3 $ |
| PARTICIPANT’S name | PARTICIPANT’S name | Rollover contributions 4 $ |
Fair market value of Archer MSA or M+C MSA 5 $ |
| Street address (including apt. no.) | Street address (including apt. no.) | Medicare+Choice MSA 6 |
|
| City, state, and ZIP code | City, state, and ZIP code | ||
| Account number (optional) | Account number (optional) | Account number (optional) | Account number (optional) |
Form 5498-MSA Cat. No. 23097L Department of the Treasury - Internal Revenue Service
2003–16 I.R.B. 800 April 21, 2003
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