b"5498 PRE-PRINTED FORMSIndividual Laser Packs5498-ESA (COVERDELL ESA5498-SA (HSA, ARCHER MSA, OR MEDICARE 5498 (IRS CONTRIBUTION INFORMATION) CONTRIBUTION INFORMATION) ADVANTAGE MSA INFORMATION)2828 VOID CORRECTED 7272 VOID CORRECTED 2727 VOID CORRECTED OMB No. 1545-15182022 Contribution2022 ContributionTotal contributions made in 2022 MSA InformationDETACH BEFORE MAILINGRESISTANT INKSUSING HEAT DETACH BEFORE MAILINGDETACH BEFORE MAILING1 Employee or self-employedMANUFACTURED ON OCR LASER BOND PAPER USING HEAT RESISTANT INKSMANUFACTURED ON OCR LASER BOND PAPER USING HEAT RESISTANT INKSON OCR LASER BOND PAPERMANUFACTUREDTRUSTEES or ISSUERS name, street address, city or town, state or1 IRA contributions (otherOMB No. 1545-0747 TRUSTEES or ISSUERS name, street address, city or town, state or1 Coverdell ESA contributionsOMB No. 1545-1815 TRUSTEES name, street address, city or town, state or province, country,persons Archer MSA province, country, and ZIP or foreign postal code than amounts in boxesprovince, country, and ZIP or foreign postal code ZIP or foreign postal code, and telephone number contributions made in 2022HSA, Archer MSA, or $ 24, 810, 13a, and 14a) IRA$ 2 Rollover contributions Coverdell ESA$ 2and 2023 for 2022 2022 Medicare Advantage 2 Rollover contributions Information Information$ Form 5498 $ Form5498-ESA TRUSTEES TIN PARTICIPANTS TIN $ Form5498-SA Copy A3 Roth IRA conversion4 RecharacterizedCopy A TRUSTEES/ISSUERS TIN BENEFICIARYS TIN Copy A $ 3 Total HSA or Archer MSA contributions made in 2023 for 2022 For amount contributions ForPARTICIPANTS name 4 Rollover contributions 5 Fair market value of HSA,Internal Revenue TRUSTEES or ISSUERS TIN PARTICIPANTS TIN $ $ ForBENEFICIARYS name Internal RevenueArcher MSA, or MA MSA Service Center5 FMV of account 6 Life insurance cost included inInternal RevenueService Centerbox 1 Service Center File with Form 1096. $ $ File with Form 1096.$ $ File with Form 1096. 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For Privacy Act andStreet address (including apt. no.) 6HSA For Privacy Act and PARTICIPANTS name 7IRA SEP SIMPLE Paperwork ReductionCity or town, state or province, country, and ZIP or foreign postal code Archer MSA Paperwork Reduction Act $ 8 SEP contributions $ 9 SIMPLE contributionsRoth IRA and PaperworkCity or town, state or province, country, and ZIP or foreign postal code Act Notice, see theAccount number (see instructions) MA MSA Notice, seeFor Privacy Act2022 General the 2022 GeneralInstructions forStreet address (including apt. no.) 10 Roth IRA contributions 11 Check if RMD for 2023 Reduction ActAccount number (see instructions) Certain InformationReturns.Instructions for$ Notice, see theForm5498-ESA 41-0852411 www.irs.gov/Form5498ESA Department of the Treasury - Internal Revenue Service Form5498-SA 41-0852411 www.irs.gov/Form5498SA Certain InformationReturns.12a RMD date 12b RMD amount Department of the Treasury - Internal Revenue ServiceCity or town, state or province, country, and ZIP or foreign postal code $ 2022 General Do Not Cut or Separate Forms on This PageDo Not Cut or Separate Forms on This Page Do Not Cut or Separate Forms on This PageDo Not Cut or Separate Forms on This PageCORRECTED (if checked) CORRECTED CORRECTED (if checked)TRUSTEES or ISSUERS name, street address, city or town, state or 13a Postponed/late contrib.1 IRA contributions (other 13b Year Instructions forCertain IRATRUSTEES or ISSUERS name, street address, city or town, state or$ 1 Coverdell ESA contributionsOMB No. 1545-1815 Coverdell ESATRUSTEES name, street address, city or town, state or province, country,1 Employee or self-employed OMB No. 1545-1518 HSA, Archer MSA, or 13c CodeOMB No. 1545-0747 province, country, and ZIP or foreign postal code ZIP or foreign postal code, and telephone number persons Archer MSADETACH BEFORE MAILINGMANUFACTURED ON OCR LASER BOND PAPER USING HEAT RESISTANT INKSDETACH BEFORE MAILINGMANUFACTURED ON OCR LASER BOND PAPER USING HEAT RESISTANT INKSprovince, country, and ZIP or foreign postal code $ than amounts in boxesInformation 2727 VOID CORRECTED contributions made in 2022 14a Repayments 24, 810, 13a, and 14a) Returns. 7272 VOID CORRECTED 2 Rollover contributions ContributionTRUSTEES name, street address, city or town, state or province, country,$ and 2023 for 2022 Medicare Advantage $ $ 14b Code 2022 ContributionTRUSTEES or ISSUERS name, street address, city or town, state or1 Coverdell ESA contributionsOMB No. 1545-1815 2022 Information ZIP or foreign postal code, and telephone number 1 Employee or self-employed OMB No. 1545-1518 2022 MSA Information$ FormInformation province, country, and ZIP or foreign postal code $ $ FormCoverdell ESATRUSTEES TIN $ persons Archer MSATotal contributions made in 2022 HSA, Archer MSA, orCopy Bcontributions made in 2022 2 Account number (see instructions) 15a assets 2 Rollover contributions15b Code(s) 5498 Copy B TRUSTEES/ISSUERS TIN BENEFICIARYS TIN2 Rollover contributions 2022 5498-ESA Copy B PARTICIPANTS TIN2and 2023 for 2022$ 2022 Form5498-SAMedicare Advantage Form5498 TRUSTEES or ISSUERS TIN $ $ 3 Roth IRA conversion$ 4 RecharacterizedBENEFICIARY'S name, stret adres, city or town, state or province, country, and ZIP or foreign postal code Form5498-ESA ContributionFor Beneciary TRUSTEES TIN PARTICIPANT'S name, stret adres $ Total contributions made in 2022 Form5498-SA MSA Information For amount contributions Information $ 3 Total HSA or Archer MSA contributions made in 2023 for 2022Department of the Treasury - Internal Revenue Service $ PARTICIPANTS TIN 3 Total HSA or Archer MSA contributions made in 2023 for 2022 Copy A41-0852411PARTICIPANTS TINwww.irs.gov/Form54985 FMV of account 6 Life insurance cost included inTRUSTEES/ISSUERS TIN BENEFICIARYS TIN Copy A This information, city or town, state or province, country, and ZIP or foreign postal code4 Rollover contributions 5 Fair market value of HSA,ForParticipantDo Not Cut or Separate Forms on This PageDo Not Cut or Separate Forms on This Page ParticipantForForis being furnishedPARTICIPANTS name $ $ HSA $ Archer MSA, or MA MSAbox 1$ $ BENEFICIARYS name Internal Revenueto the IRS. 4 Rollover contributions6 5 Fair market value of HSA,Internal Revenue Archer MSA, or MA MSA Service CenterPARTICIPANT'Sname,stretadres,cityortown,stateorprovince,country,andZIPorforeignpostalcode 7 IRA SEP SIMPLE This informationService Center $ Archer MSA File with Form 1096. 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Copy C TRUSTEES or ISSUERS name, street address, city or town, state or$ $ $ 2022 Form5498-ESA Copy C TRUSTEES name, street address, city or town, state or province, country,1 Employee or self-employed and 2023 for 2022 2022 Form5498-SA Copy CPARTICIPANTS name SEP SIMPLE 3 Roth IRA conversionForm 5498 province, country, and ZIP or foreign postal codeTRUSTEES/ISSUERS TIN 1 Coverdell ESA contributionsOMB No. 1545-1815 ContributionZIP or foreign postal code, and telephone numberTRUSTEES TIN persons Archer MSA$ Medicare Advantage amount contributions $ OMB No. 1545-1518 MSA InformationStreet address (including apt. no.) $ $ $ 5Roth IRA $ 4 RecharacterizedTrustee or IssuerForTRUSTEES/ISSUERS TIN $ BENEFICIARYS TIN2 Rollover contributions FormCoverdell ESAInformation For Trustee TRUSTEES TIN TRUSTEES TIN PARTICIPANT'S name, stre res $ 2PARTICIPANTS TIN $ Form$ 3 Total HSA or Archer MSA contributions made in 2023 for 2022 For Trusteecontributions made in 2022 2 Total contributions made in 2022 HSA, Archer MSA, or Form5498 (keep for your records) SEP contributions $ 9 SIMPLE contributions For Privacy ActBENEFICIARY'S name, stret adres, city or town, state or province, country, and ZIP or foreign postal code 5498-ESA Copy B or State Copy t ad $ 2022 5498-SA 5 Fair market value of HSA,or State CopyTRUSTEES or ISSUERS TIN $PARTICIPANTS TIN $ Department of the Treasury - Internal Revenue Service BENEFICIARYS TIN2 Rollover contributions $ 2022 ContributionFor Privacy Act, city or town, state or province, country, and ZIP or foreign postal code4 Rollover contributionsFormMSA Information Copy BFor Privacy Act www.irs.gov/Form5498 $ PARTICIPANTS TINand 2023 for 2022 Medicare Advantage 10 Roth IRA contributions 11 Check if RMD for 2023 and PaperworkBENEFICIARY'S name, stret adres, city or town, state or province, country, and ZIP or foreign postal code FormInformation and PaperworkPARTICIPANT'S name, stret adres $ Total contributions made in 2022 5498-SA $ and Paperwork FMV of account 6 Life insurance cost included in3 Total HSA or Archer MSA contributions made in 2023 for 2022Archer MSA, or MA MSAPARTICIPANT'Sname,stretadres,cityortown,stateorprovince,country,andZIPorforeignpostalcode 7 IRA SEP Reduction ActTRUSTEES/ISSUERS TIN BENEFICIARYS TIN Copy A For Beneciary Reduction Act, city or town, state or province, country, and ZIP or foreign postal code $ HSA 5 Archer MSA, or MA MSA ForFor Reduction Act box 112a RMD date 12b RMD amount Notice, see the5498-ESA This information Notice, see thePARTICIPANTS TIN 4 Rollover contributions6 Archer MSA Fair market value of HSA,ParticipantSIMPLE Roth IRA 3 Total HSA or Archer MSA contributions made in 2023 for 2022 Copy ACity or town, state or province, country, and ZIP or foreign postal code CORRECTED (if checked)$ $ 8 13cCode 2022 General For Privacy ActBENEFICIARYS name Foris being furnished 2022 GeneralPARTICIPANTS name $ $ HSA MA MSA $ Internal RevenueNotice, see theprovince, country, and ZIP or foreign postal code 13a Postponed/late contrib.1 IRA contributions (other 13b Year SEP contributions Instructions forCertainand PaperworkAccount number (see instructions) Internal RevenueInformation Account number (see instructions) $ 4 Rollover contributions6 $ 5 Fair market value of HSA,Service Center This information2022 General for TRUSTEES or ISSUERS name, street address, city or town, state orthan amounts in boxes OMB No. 1545-0747 $ 9 SIMPLE contributions Service Center Archer MSA, or MA MSA Instructions$ 24, 810, 13a, and 14a) Information IRAReduction ActStreet address (including apt. no.) 5498-ESA File with Form 1096. to the IRS.Instructions forCertain Street address (including apt. no.) 5498-SA 6HSA Archer MSA File with Form 1096. is being furnishedCertainReturns. 14a Repayments 14b Code10 Roth IRA contributions 11 Check if RMD for 2023 For Privacy Act andReturns. 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Instructions14a RepaymentscontributionsDepartment of the Treasury - Internal Revenue Service Certain InformationReturns. 41-0852411PARTICIPANTS TINwww.irs.gov/Form54985 FMV of account $ 6 Life insurance cost included inParticipantForForm5498-ESA L58ESAA TRUSTEES or ISSUERS name, street address, city or town, state or$ 1 Coverdell ESA contributionsOMB No. 1545-1815 Coverdell ESAForm5498-SA L58SAA TRUSTEES name, street address, city or town, state or province, country,1 Employee or self-employed OMB No. 1545-1518 HSA, Archer MSA, or box 1 province, country, and ZIP or foreign postal code Department of the Treasury - Internal Revenue Service 41-0852411 5133 www.irs.gov/Form5498SA Department of the Treasury - Internal Revenue Service41-0852411 5126 www.irs.gov/Form5498ESA ZIP or foreign postal code, and telephone number persons Archer MSA contributions made in 2022 CORRECTED (if checked)PARTICIPANT'Sname,stretad Account number (see instructions) , or or ZIPorforeignpostalcode $ 7 IRA 15a$ 15b Code(s) This informationprovince, country, and ZIP or foreign postal code CORRECTED 2022 ContributionTRUSTEES name, street address, city or town, state or province, country,$ 2and 2023 for 2022 2022 Medicare Advantage rescitytown, stateprovince,country,and $ 8 SEP contributionsSEP$ assetsSIMPLE9 SIMPLE contributionsRoth IRA Department of the Treasury - Internal Revenue Service TRUSTEES or ISSUERS name, street address, city or town, state or$ 1 Coverdell ESA contributions2 Rollover contributionsOMB No. 1545-1815 FormCoverdell ESAInformation ZIP or foreign postal code, and telephone number PARTICIPANTS TIN $ 1 Employee or self-employed OMB No. 1545-1518 Form5498-SA MSA Informationpersons Archer MSA Total contributions made in 2022 HSA, Archer MSA, or contributions made in 2022 Form5498 www.irs.gov/Form5498 is beingTRUSTEES/ISSUERS TIN $ 2022 5498-ESA Copy C TRUSTEES TIN 2and 2023 for 2022 2022 Medicare AdvantageCopy C$ furnished toBENEFICIARYS TIN2 Rollover contributions Contribution$ 3 Total HSA or Archer MSA contributions made in 2023 for 202210 Roth IRA contributions 11 If checked, required minimumthe IRS. FormInformation For Trustee PARTICIPANT'S name, stret adres $ Total contributions made in 2022 Form5498-SA MSA Information For Trusteeprovince, country, and ZIP or foreign postal code VOID $ CORRECTED $ distribution for 2023 OMB No. 1545-0747 BENEFICIARY'S name, stre BENEFICIARY'S name, stret adres $ 5498-ESA For Beneciary or State Copy TRUSTEES TIN t adres , city or town, state or province, country, and ZIP or foreign postal code $ 4 Rollover contributions 6 $ 5 Fair market value of HSA,Foror State Copy12a RMD date 12b RMD amount TRUSTEES/ISSUERS TIN , city or town, state or province, country, and ZIP or foreign postal code Copy B For Privacy ActPARTICIPANTS TIN $ 3 Total HSA or Archer MSA contributions made in 2023 for 2022 Copy BFor Privacy Act BENEFICIARYS TIN Archer MSA, or MA MSATRUSTEES or ISSUERS name, street address, city or town, state orand Paperwork$ HSA Archer MSA, or MA MSA and Paperwork 13a Postponed/late contrib.1 IRA contributions (other than amounts in boxes13b Year13c CodeIRAt adres, city or town, state or province, country, and ZIP or foreign postal code This informationReduction ActPARTICIPANT'S name, stre , city or town, state or province, country, and ZIP or foreign postal code $ 4 Rollover contributions $ 5 Fair market value of HSA,Reduction Act $ 24, 810, 13a, and 14a) is being furnishedNotice, see theArcher MSA ParticipantNotice, see the 14a Repayments 14b Code 2022 General Account number (see instructions) $ assets $ 2 Rollover contributions 2022 ContributionAccount number (see instructions) 2022 General Account number (see instructions) 6HSA MA MSA Instructions for Certainto the IRS.Instructions for15a$ 15b Code(s) Form 5498 Information Certain Archer MSA This informationInformationInformation4 RecharacterizedCopy C Account number (see instructions)Form5498-ESA www.irs.gov/Form5498ESA Returns. Form5498-SA MA MSA is being furnishedReturns.$ 3 Roth IRA conversioncontributions Department of the Treasury - Internal Revenue Service Account number (see instructions) www.irs.gov/Form5498SA Department of the Treasury - Internal Revenue Serviceamount to the IRS.Form5498 TRUSTEES or ISSUERS TIN PARTICIPANTS TIN $ Department of the Treasury - Internal Revenue ServiceL58B (keep for your records) 5171 www.irs.gov/Form5498 $5 FMV of account 6 Life insurance cost included inTrustee or IssuerForForm5498-ESA L58ESAB(keep for your records) 5127 www.irs.gov/Form5498ESA Department of the Treasury - Internal Revenue Service Form5498-SA L58SAB (keep for your records) 5134 www.irs.gov/Form5498SA Department of the Treasury - Internal Revenue Servicebox 1 VOID CORRECTED$IRA $ VOID CORRECTED OMB No. 1545-1815 TRUSTEES name, street address, city or town, state or province, country,1 Employee or self-employed OMB No. 1545-1518PARTICIPANT'Sname,stretadres,cityortown,stateorprovince,country,andZIPorforeignpostalcode 7 SIMPLE TRUSTEES or ISSUERS name, street address, city or town, state or1 Coverdell ESA contributions ZIP or foreign postal code, and telephone number contributions made in 2022HSA, Archer MSA, or province, country, and ZIP or foreign postal code persons Archer MSA $ 8 SEP contributionsSEP $ 9 SIMPLE contributionsRoth IRA and Paperwork$ 2 Rollover contributions Coverdell ESA$ 2and 2023 for 2022 Medicare Advantage 10 Roth IRA contributions 11 Check if RMD for 2023 For Privacy Act2022 ContributionTotal contributions made in 2022 2022 MSA InformationReduction ActInformation$ 12b RMD amount Notice, see theTRUSTEES/ISSUERS TIN BENEFICIARYS TIN $ Form5498-ESA Copy C TRUSTEES TIN PARTICIPANTS TIN $ Form5498-SA Copy C12a RMD date 3 Total HSA or Archer MSA contributions made in 2023 for 202213a Postponed/late contrib. $ 13c Code 2022 General BENEFICIARY'S name, stret adres, city or town, state or province, country, and ZIP or foreign postal code For Trustee PARTICIPANT'S name, stret adres, city or town, state or province, country, and ZIP or foreign postal code $ 4 Rollover contributions 5 Fair market value of HSA,For Trustee13b Year Instructions for or State Copy Archer MSA, or MA MSA or State Copy$ 14b Code Certain For Privacy Act$ $ For Privacy Act 14a Repayments Information and Paperworkand Paperwork Returns.Reduction Act6HSA Reduction Act Account number (see instructions) $ Archer MSA Notice, see the15a assets 15b Code(s) Notice, see the MA MSA 2022 General for 2022 General Form5498 L58C 5172 $ Department of the Treasury - Internal Revenue Service Account number (see instructions) Instructions for Account number (see instructions) InstructionsCertainwww.irs.gov/Form5498 Certain InformationInformationReturns. Returns.Form5498-ESA L58ESAC 5128 www.irs.gov/Form5498ESA Department of the Treasury - Internal Revenue Service Form5498-SA L58SAC 5135 www.irs.gov/Form5498SA Department of the Treasury - Internal Revenue ServiceRequired Envelope: Required Envelope: Required Envelope:APEX: DWMR or DWMRS APEX/TFP: DW19W or DW19WS APEX/TFP: DW19W or DW19WSTFP: 77771 or 77772APEX - Sheets per packTFP - Forms per pack50s500s100s1000sFORM DESCRIPTIONL58AL58A50051705170B5498 Federal Copy A1 Page Equals 2 FormsL58BL58B50051715171B5498 Participant Copy B1 Page Equals 2 FormsL58CL58C50051725172B5498 Trustee or Issuer Copy C1 Page Equals 2 FormsL58ESAAN/A5126N/A5498-ESA Federal Copy A1 Page Equals 3 FormsL58ESAB N/A5127N/A5498-ESABeneficiaryCopyB1 Page Equals 3 FormsL58ESAC N/A5128N/A5498-ESA Trustee Copy C and/or State Copy1 Page Equals 3 FormsL58SAAN/A5133N/A5498-SA Federal Copy A1 Page Equals 3 FormsL58SABN/A5134N/A5498-SA Participant Copy B1 Page Equals 3 FormsL58SACN/A5135N/A5498-SA Trustee Copy C and/or State Copy1 Page Equals 3 Forms37"