--- ## Page 1 # Optum Financial® P.O. Box 271629 | Salt Lake City, UT 84127-1629 019OFSTXR0011003-15440-01 JOHAN JONGSMA 851 BRIGHTWATERS BLVD NE SAINT PETERSBURG FL 33704-3719 **Important IRS Tax Form 5498-SA** Dear JOHAN: The enclosed IRS tax form 5498-SA shows your 2022 contributions to your HSA. Please use this information to fill out IRS tax form 8889 which is what you'll need to submit your taxes. To access IRS tax form 8889 sign in at irs.gov and navigate to Forms and Publications. **Here's what you need to know:** - Box 2 shows your total contributions made for 2022 including those made in 2022 for 2021, if applicable. - You have until the tax filing deadline of this year to submit contributions for 2022. If you make any contributions in 2023 before the tax deadline for 2022 you will receive an updated 5498-SA in May. - To get your total contributions for 2022 add Box 2 plus Box 3. Please note if you made any contributions in 2022 for 2021 you need to review your updated 5498 for 2021 and subtract that from Box 3. - The Fair Market Value consists of your HSA cash balance and any investment balance as of 12/31/2022. - If you had a reportable distribution for 2022, you'll also get tax form 1099-SA. If you did not use (no distributions) your HSA in 2022 you will not get a 1099-SA. **Ready to say goodbye to printed forms?** Sign in to your account to access your HSA, click "Accounts" from menu bar, select "Account Management" and update your Communications preference to "Online." **Questions?** Please sign in at **optumbank.com** to access your HSA or call 1-866-234-8913. ☐ CORRECTED (if checked) | | | |---|---| | TRUSTEE'S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone number | Optum Bank
P.O. Box 271629
Salt Lake City UT 84127-1629 | | | | | |---|---|---| | 1 Employee or self-employed person's Archer MSA contributions made in 2022 and 2023 for 2022
$ 0 | OMB No. 1545-1518 | **HSA, Archer MSA, or Medicare Advantage MSA Information** | | 2 Total contributions made in 2022
$ 0.00 | **2022**
Form **5498-SA** | | | TRUSTEE'S federal identification number | PARTICIPANT'S social security number | | | |---|---|---|---| | 470858534 | ****4568 | 3 Total HSA or Archer MSA contributions made in 2023 for 2022 $0.00 | **Copy B**
**For Participant** | | | | | | |---|---|---|---| | PARTICIPANT'S name
JOHAN JONGSMA | 4 Rollover contributions
$ 0.00 | 5 Fair market value of HSA, Archer MSA, or MA MSA
$ 1884.44 | This information is being furnished to the Internal Revenue Service. | | Street address (including apt. no.)
851 BRIGHTWATERS BLVD NE | 6 HSA ☒
Archer MSA ☐
MA MSA ☐ | | | | City or town, state or province, country, and ZIP or foreign postal code
SAINT PETERSBURG FL 33704-3719 | | | | | Account number (see instructions)
412231515 | | | | Form **5498-SA** (keep for your records) www.irs.gov/form5498sa Department of the Treasury - Internal Revenue Service © 2022 Optum, Inc. All rights reserved. 70876E-052022 --- ## Page 2 **Note: Fees and interest earnings are not considered contributions or distributions and are not reported on either tax form. If you have questions regarding specific circumstances, you should contact a competent tax advisor or the IRS.** ### 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 make 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 identification number.** 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 identification number to the IRS taxable amount. **Account number.** May show an account or other unique number the trustee assigned to distinguish your account. **Box 1.** Shows contributions you made to your Archer MSA in 2022 and through APR 18, 2023, for 2022. You may be able to deduct this amount on your 2022 Form 1040. See the Form 1040 instructions. **Note:** The information in boxes 2 and 3 is provided for IRS use only. **Box 2.** Shows the total contributions made in 2022 to your HSA or Archer MSA. 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 2023 for 2022. **Box 4.** Shows any rollover contribution from an Archer MSA to this Archer MSA in 2022 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 2022. **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. © 2022 Optum, Inc. All rights reserved. 708776E-052022

IRS Form 5498-SA Optum Bank HSA 2022 Account 412231515

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