b"PRE-PRINTED 5498 FORMSINDIVIDUAL LASER PACKS5498ESA COVERDELL ESA5498SA HSA, ARCHER MSA, OR MEDICARE 5498 IRS CONTRIBUTION INFORMATION CONTRIBUTION INFORMATION ADVANTAGE MSA INFORMATION2828 VOID CORRECTED 7272 VOID CORRECTED 2727 VOID CORRECTED OMB No. 1545-1518 DETACH BEFORE MAILINGRESISTANT INKSUSING HEAT DETACH BEFORE MAILINGDETACH BEFORE MAILINGTRUSTEES or ISSUERS name, street address, city or town, state orthan amounts in boxesOMB 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,1 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 PAPERMANUFACTUREDprovince, country, and ZIP or foreign postal code 1 IRA contributions (otherprovince, country, and ZIP or foreign postal code ZIP or foreign postal code, and telephone number contributions made in 2021HSA, Archer MSA, or persons Archer MSA $ 24, 810, 13a, and 14a) IRA$ 2 Rollover contributions Coverdell ESA$ 2and 2022 for 2021 2021 Medicare Advantage 2021 Contribution2021 ContributionTotal contributions made in 2021 MSA Information2 Rollover contributions Information Information$ Form 5498 $ Form5498-ESA TRUSTEES TIN PARTICIPANT'S 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 2022 for 2021 For amount contributions ForPARTICIPANT'S 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. Street address (including apt. no.) For Privacy Act andStreet address (including apt. no.) 6HSA For Privacy Act and Paperwork PARTICIPANTS name 7IRA SEP SIMPLE Paperwork ReductionCity or town, state or province, country, and ZIP or foreign postal code Archer MSA Reduction Act 8 SEP contributions 9 SIMPLE contributionsRoth IRA City or town, state or province, country, and ZIP or foreign postal code Act Notice, see theMANotice, see Street address (including apt. no.) $ $ For Privacy ActAccount number (see instructions) 2021 GeneralAccount number (see instructions) MSA the 2021 General forand PaperworkInstructions for Instructions10 Roth IRA contributions 11 Check if RMD for 2022 Reduction ActCertain InformationReturns. Certain InformationReturns.$ 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 Department of the Treasury - Internal Revenue Service12a RMD date 12b RMD amountCity or town, state or province, country, and ZIP or foreign postal code $ 2021 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 province, country, and ZIP or foreign postal code 14a Repayments 14b Code 13c CodeOMB No. 1545-0747 Information 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 INKS$ than amounts in boxes contributions made in 2021 24, 810, 13a, and 14a) Returns. 7272 VOID CORRECTED 2 Rollover contributions Contribution2727 VOID CORRECTED $ and 2022 for 2021 Medicare Advantage $ 2021 ContributionTRUSTEES or ISSUERS name, street address, city or town, state or1 Coverdell ESA contributionsOMB No. 1545-1815 2021 Information TRUSTEES name, street address, city or town, state or province, country,1 Employee or self-employed OMB No. 1545-1518 2021 MSA InformationAccount number (see instructions) $ $ 3 Roth IRA conversionForm 5498 Information province, country, and ZIP or foreign postal code BENEFICIARYS TIN2 Rollover contributions $ FormCoverdell ESACopy B ZIP or foreign postal code, and telephone number $ contributions made in 20212021 HSA, Archer MSA, orCopy Bpersons Archer MSA 2 Total contributions made in 202115a assets 2 Rollover contributions15b Code(s) 4 RecharacterizedCopy B TRUSTEES/ISSUERS TIN $ 2021 5498-ESA TRUSTEES TIN PARTICIPANT'S TIN2and 2022 for 2021$ Form5498-SAContributionMedicare Advantage $ amount contributions Information For Beneciary TRUSTEES TIN PARTICIPANT'S name, stret adres $ Total contributions made in 2021 Form5498-SA MSA Information For 3 Total HSA or Archer MSA contributions made in 2022 for 2021Form5498 TRUSTEES or ISSUERS TIN $ Department of the Treasury - Internal Revenue Service BENEFICIARY'S name, stret adres, city or town, state or province, country, and ZIP or foreign postal code Form5498-ESA , city or town, state or province, country, and ZIP or foreign postal code $ 4 Rollover contributions 5 Fair market value of HSA, $ $ Copy A41-0852411PARTICIPANTS TINwww.irs.gov/Form54985 FMV of account 6 Life insurance cost included inTRUSTEES/ISSUERS TIN BENEFICIARYS TIN Copy A This informationPARTICIPANT'S TIN 3 Total HSA or Archer MSA contributions made in 2022 for 2021Archer MSA, or MA MSA ParticipantDo Not Cut or Separate Forms on This PageDo Not Cut or Separate Forms on This Page ParticipantForForis being furnishedPARTICIPANT'S name $ $ HSA $ For box 1$ $ BENEFICIARYS name Internal Revenueto the IRS. 4 Rollover contributions6 5 Fair market value of HSA,Internal Revenue PARTICIPANT'Sname,stretadres,cityortown,stateorprovince,country,andZIPorforeignpostalcode 7 IRA SEP SIMPLE This informationService Center $ $ Archer MSA, or MA MSA Service Center This information Archer MSA2828 VOID CORRECTED $ 8 SEP contributionsOMB No. 1545-07479 SIMPLE contributionsRoth IRA is beingStreet address (including apt. no.) 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City or town, state or province, country, and ZIP or foreign postal code Paperwork ReductionAccount number (see instructions) MAReduction Act $ 24, 810, 13a, and 14a) 12b RMD amount ContributionForm5498-ESA (keep for your records) VOID www.irs.gov/Form5498ESA Act Notice, see theAccount number (see instructions)Form5498-SA (keep for your records)MSA www.irs.gov/Form5498SA Notice, seeVOID $ 2021 Information Account number (see instructions) CORRECTED Instructions for CORRECTED (if checked) the 2021 General for $ 2 Rollover contributions12a RMD date 5498 $ OMB No. 1545-0747 Form5498-ESA TRUSTEES or ISSUERS name, street address, city or town, state or2021 GeneralForm5498-SA TRUSTEES name, street address, city or town, state or province, country,Department of the Treasury - Internal Revenue ServiceDepartment of the Treasury - Internal Revenue Service InstructionsCORRECTED Certain InformationReturns. Certain InformationReturns. TRUSTEES or ISSUERS TIN province, country, and ZIP or foreign postal codeamount $ $ Form 1 IRA contributions (otherCopy A IRAprovince, country, and ZIP or foreign postal code $ 1 Coverdell ESA contributionsOMB No. 1545-1815 Coverdell ESADo Not Cut or Separate Forms on This PageDo Not Cut or Separate Forms on This Page HSA, Archer MSA, or TRUSTEES or ISSUERS name, street address, 3 Roth IRA conversion city or town, state or 13a Postponed/late contrib.than amounts in boxes14b Code 13c Code41-0852411 www.irs.gov/Form5498ESA Department of the Treasury - Internal Revenue Service ZIP or foreign postal code, and telephone numberwww.irs.gov/Form5498SA Department of the Treasury - Internal Revenue Service4 Recharacterized 13b Year 41-0852411 1 Employee or self-employed OMB No. 1545-1518 DETACH BEFORE MAILINGDETACH BEFORE MAILINGDETACH BEFORE MAILING MANUFACTURED ON OCR LASER BOND PAPER USING HEAT RESISTANT INKSMANUFACTURED ON OCR LASER BOND PAPER USING HEAT RESISTANT INKSON OCR LASER BOND PAPER USING HEAT RESISTANT INKSMANUFACTUREDpersons Archer MSA PARTICIPANTS TIN $ 5 FMV of account 14a Repayments contributions24, 810, 13a, and 14a) ForContributionDo Not Cut or Separate Forms on This PageDo Not Cut or Separate Forms on This Page ContributionTRUSTEES name, street address, city or town, state or province, country,$ contributions made in 20212021 Medicare Advantage CORRECTED CORRECTED (if checked)$ 6 Life insurance cost included in2021 Information TRUSTEES or ISSUERS name, street address, city or town, state or1 Coverdell ESA contributions2 Rollover contributionsOMB No. 1545-1815 2021 Information ZIP or foreign postal code, and telephone number and 2022 for 2021OMB No. 1545-1518 MSA InformationPARTICIPANTS name 7IRA SEP SIMPLE $ 2 Rollover contributions Internal RevenueCopy C province, country, and ZIP or foreign postal code $ $ 2021 FormCoverdell ESACopy C 2727 VOID CORRECTED $ 1 Employee or self-employed2021 FormHSA, Archer MSA, orCopy Bbox 1 15b Code(s) Service Center 7272 VOID CORRECTED OMB No. 1545-1815 5498-ESA TRUSTEES name, street address, city or town, state or province, country,persons Archer MSApersons Archer MSAMedicare Advantage Account number (see instructions) 15a assets $ $ 3 Roth IRA conversionFile with Form 1096. TRUSTEES or ISSUERS name, street address, city or town, state or1 Coverdell ESA contributions ContributionZIP or foreign postal code, and telephone numberTRUSTEES TIN 1 Employee or self-employed and 2022 for 202125498-SATotal contributions made in 2021contributions made in 2021 $$ Form 5498 BENEFICIARYS TIN2 Rollover contributions Information PARTICIPANT'S TIN OMB No. 1545-1518 MSA InformationTRUSTEES or ISSUERS TIN $ 8 SEP contributions Roth IRA 6contributions BENEFICIARY'S name, stret adres, city or town, state or province, country, and ZIP or foreign postal code 5498-ESA or State Copy PARTICIPANT'S TINand 2022 for 2021$ 3HSA, Archer MSA, orCopy B ParticipantForm(keep for your records) $ $ $ 5amount $ 4 Recharacterizedprovince, country, and ZIP or foreign postal codeTRUSTEES/ISSUERS TIN $ 2 Rollover contributions $ 2021 FormCoverdell ESACopy B For Trustee TRUSTEES TIN PARTICIPANT'S name, stret adres $ 2contributions made in 2021 2$ Total HSA or Archer MSA contributions made in 2022 for 2021 For 9 SIMPLE contributions Total contributions made in 2021 5498-SA 5 Fair market value of HSA, 5498 www.irs.gov/Form5498 Department of the Treasury - Internal Revenue Service TRUSTEES/ISSUERS TIN BENEFICIARYS TIN ContributionFor Privacy ActTotal contributions made in 2021 2021 Medicare Advantage PARTICIPANTS TIN For Privacy Act, city or town, state or province, country, and ZIP or foreign postal code4 Rollover contributionsFormArcher MSA, or MA MSAFMV of account Life insurance cost included inMSA InformationStreet address (including apt. no.) PARTICIPANT'Sname,stretadres,cityortown, 10 Roth IRA contributions or or 11 Check if RMD for 2022 7 SEP and PaperworkTrustee or IssuerForTRUSTEES/ISSUERS TIN BENEFICIARYS TIN Form5498-ESA Information For Beneciary and PaperworkTRUSTEES TIN PARTICIPANT'S name, stret adres, city or town, state or province, country, and ZIP or foreign postal code $ 3 Total HSA or Archer MSA contributions made in 2022 for 2021 6 ForThis information $IRA Reduction ActBENEFICIARY'S name, stret adres, city or town, state or province, country, and ZIP or foreign postal code Copy A This informationReduction ActPARTICIPANT'S TIN $ 3Form$ HSA $ Copy A Participantbox 1$ $ 5498-SA Archer MSA, or MA MSA12a RMD date 12b RMD amount Notice, see the$ Notice, see the4 Rollover contributions 5 Fair market value of HSA, City or town, state or province, country, and ZIP or foreign postal code stateprovince,country,andZIPforeignpostalcode 8 SEP contributions 2021 General BENEFICIARYS name Foris being furnished 2021 GeneralPARTICIPANT'S name $ Total HSA or Archer MSA contributions made in 2022 for 2021 Foris being furnished Archer MSACORRECTED (if checked)$ 13c CodeOMB No. 1545-0747 SIMPLE Roth IRA For Privacy ActInternal Revenue$ HSA MAInternal Revenueto the IRS.TRUSTEES or ISSUERS name, street address, city or town, state or 13a Postponed/late contrib.1 IRA contributions (other 13b Year $ Instructions forCertainand PaperworkAccount number (see instructions) Service Center Information Account number (see instructions) $ 4 Rollover contributions6 Archer MSAArcher MSA, or MA MSAMSA $ Service Center This information 9 SIMPLE contributions 5 Fair market value of HSA, province, country, and ZIP or foreign postal code $ than amounts in boxes Information IRAReduction ActFile with Form 1096. to the IRS.Instructions forCertain MAFile with Form 1096. is being furnished $14b Code10 Roth IRA contributions Returns. 14a Repayments 24, 810, 13a, and 14a) 11 Check if RMD for 2022 Notice, see theStreet address (including apt. no.) 5498-ESA For Privacy Act andReturns. 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Form5498-SA 6HSA MSA $ For Privacy Act andto the IRS.Account number (see instructions) $ $ $ 2021 ContributionAccount number (see instructions)Formwww.irs.gov/Form5498ESA Department of the Treasury - Internal Revenue Service Account number (see instructions) (keep for your records) www.irs.gov/Form5498SA Department of the Treasury - Internal Revenue Service15a assets $ 2 Rollover contributions12a RMD date 5498 $ Information 2021 General City or town, state or province, country, and ZIP or foreign postal code Paperwork ReductionCity or town, state or province, country, and ZIP or foreign postal code Archer MSA Paperwork 12b RMD amountReduction Act 15b Code(s)13a Postponed/late contrib.Form13b Year13c Code Instructions forCertainForm5498-ESA (keep for your records) www.irs.gov/Form5498ESA Act Notice, see theAccount number (see instructions)Form5498-SA MAwww.irs.gov/Form5498SA Notice, seeForm5498 L58A 41-0852411 5170 $ $ amount $ $ 14b Code Copy B Information Account number (see instructions) VOID CORRECTED 2021 General (keep for your records)MSA CORRECTED (if checked) the 2021 General for3 Roth IRA conversion4 RecharacterizedDepartment of the Treasury - Internal Revenue Service Department of the Treasury - Internal Revenue ServiceTRUSTEES or ISSUERS TIN 14a Repaymentscontributions 15b Code(s) ParticipantForReturns.L58ESAA TRUSTEES or ISSUERS name, street address, city or town, state or$ Instructions forCoverdell ESAForm5498-SA L58SAA TRUSTEES name, street address, city or town, state or province, country,1 Employee or self-employedInstructions HSA, Archer MSA, or Department of the Treasury - Internal Revenue Service Certain InformationReturns. Certain InformationReturns.PARTICIPANTS TINwww.irs.gov/Form54985 FMV of account $ 6 Life insurance cost included inForm5498-ESA province, country, and ZIP or foreign postal code 1 Coverdell ESA contributionsOMB No. 1545-1815 ZIP or foreign postal code, and telephone numberwww.irs.gov/Form5498SA Department of the Treasury - Internal Revenue ServiceOMB No. 1545-1518box 1 41-0852411 5126 www.irs.gov/Form5498ESA Department of the Treasury - Internal Revenue Service 41-0852411 5133 persons Archer MSA contributions made in 2021 CORRECTED (if checked)PARTICIPANT'Sname,stretad Account number (see instructions) , or or ZIPorforeignpostalcode $ 7 IRA 15a$ This informationprovince, country, and ZIP or foreign postal code CORRECTED OMB No. 1545-1815 2021 ContributionTRUSTEES name, street address, city or town, state or province, country,persons Archer MSA 2and 2022 for 2021OMB No. 1545-1518 2021 Medicare Advantage rescitytown, stateprovince,country,and $ 8 SEP contributionsSEP$ assetsSIMPLE9 SIMPLE contributionsRoth IRA is beingTRUSTEES or ISSUERS name, street address, city or town, state or$ 1 Coverdell ESA contributions2 Rollover contributions FormCoverdell ESAInformation ZIP or foreign postal code, and telephone number PARTICIPANT'S TIN $ 1 Employee or self-employedForm5498-SA MSA Information$Total contributions made in 2021contributions made in 2021HSA, Archer MSA, or Form5498 www.irs.gov/Form5498 Department of the Treasury - Internal Revenue Service TRUSTEES/ISSUERS TIN $ 2021 5498-ESA Copy C TRUSTEES TIN 2and 2022 for 2021 2021 Medicare AdvantageCopy B$ furnished toBENEFICIARYS TIN2 Rollover contributions Contribution$ MSA Information10 Roth IRA contributions 11distribution for 2022 the IRS. BENEFICIARY'S name, stret adres $ Form5498-ESA Information For Trustee TRUSTEES TIN PARTICIPANT'S name, stret adres $ Total contributions made in 2021 5498-SA 5 Fair market value of HSA,For If checked, required minimum3 Total HSA or Archer MSA contributions made in 2022 for 2021$ $ TRUSTEES/ISSUERS TIN , city or town, state or province, country, and ZIP or foreign postal code or State Copy , city or town, state or province, country, and ZIP or foreign postal code $ 4 Rollover contributionsFormArcher MSA, or MA MSA Copy B Participant12a RMD date 12b RMD amount BENEFICIARYS TIN Copy B For Privacy ActPARTICIPANT'S TIN $ 3 Total HSA or Archer MSA contributions made in 2022 for 2021province, country, and ZIP or foreign postal code VOID CORRECTED OMB No. 1545-0747 BENEFICIARY'S name, stret adres, city or town, state or province, country, and ZIP or foreign postal code For Beneciary and PaperworkPARTICIPANT'S name, stret adres, city or town, state or province, country, and ZIP or foreign postal code $ HSA $ For 13a Postponed/late contrib.1 IRA contributions (other than amounts in boxes13b Year13c CodeIRAThis informationReduction Act$ 4 Rollover contributions6 Archer MSA 5 Fair market value of HSA,Participant This information TRUSTEES or ISSUERS name, street address, city or town, state or24, 810, 13a, and 14a) is being furnishedNotice, see the$ Archer MSA, or MA MSA is being furnished $14a Repayments 14b Code$ $ 2 Rollover contributions 2021 ContributionAccount number (see instructions) 2021 General Account number (see instructions) 6HSA MAThis informationto the IRS.Information to the IRS.Instructions forCertainArcher MSA MSAAccount number (see instructions) 15a assets $ 15b Code(s) Form 5498 Information MAis being furnished Returns.MSA to the IRS.Form5498 TRUSTEES or ISSUERS TIN 5171 $ $ 3 Roth IRA conversion$ 4 RecharacterizedCopy C Account number (see instructions)Form5498-ESA www.irs.gov/Form5498ESA Department of the Treasury - 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Internal Revenue Service Account number (see instructions) Instructions forCertain Account number (see instructions) MSA to the IRS.www.irs.gov/Form5498 InformationReturns.Form5498-ESA L58ESAC 5128 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 ServiceApex DWMR or DWMRS Apex DW19 or DW19S Apex DW19 or DW19STFP 77771 or 77772 required envelope TFP 22221 or 22222 required envelope TFP 22221 or 22222 required envelopeAPEX Sheets per packTFP Forms per pack50s500s100s1000sFORM DESCRIPTIONL58AL58A50051705170BLaser 5498 Federal Copy A1 Page Equals 2 FormsL58BL58B50051715171BLaser 5498 Participant Copy B1 Page Equals 2 FormsL58CL58C50051725172BLaser 5498 Trustee or Issuer Copy C1 Page Equals 2 FormsL58ESAAN/A5126N/ALaser 5498ESA Federal Copy A1 Page Equals 3 FormsL58ESAB N/A5127N/ALaser 5498ESA Beneficiary Copy B1 Page Equals 3 FormsL58ESAC N/A5128N/ALaser 5498ESA Trustee Copy C and/or State Copy1 Page Equals 3 FormsL58SAAN/A5133N/ALaser 5498SA Federal Copy A1 Page Equals 3 FormsL58SABN/A5134N/ALaser 5498SA Participant Copy B1 Page Equals 3 FormsL58SACN/A5135N/ALaser 5498SA Trustee Copy C and/or State Copy1 Page Equals 3 Forms38"