Form 5498-SA HSA, Archer MSA, or Medicare Advantage MSA Information Participant Copy B

(9380)
HSA, Archer MSA, or Medicare Advantage MSA Information Use Form 5498-SA Copy B to print and mail payment information to the participant. 5498-SA Forms are 3up on an 8 1/2 x 11" sheet with a 1/2" side perforation and are printed on 20# laser paper. Order the quantity equal to the number of participants for which you file. Mail to participants in compatible window envelopes.
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Quantity / Unit Price
1 / Free Sample
25 - 49 / $0.49
50 - 99 / $0.326
100 - 199 / $0.188
200 - 499 / $0.157
500 - 999 / $0.1282
1000 - 2499 / $0.1088
2500 - 4999 / $0.098
5000+ / $0.0878
Enter Quantity
First Text
Minimum order of 25
or increments of 25
$000.00
Construction: Laser Preprinted
Form: 5498-SA
Form Name: HSA, Archer MSA, or Medicare Advantage MSA Information
Pages: 1
Size: 8 1/2" x 11"
Copies_(Left to Right, Top to Bottom): B - Participant
Forms /Sheet: 3up
Ink Color: Black
Horizontal Perforation: 3 2/3", 7 1/3"
Vertical Perforation: 1/2"