HSA, Archer MSA, or Medicare Advantage MSA Information

Forms and Documents

Document Name	Status
Form Form 5498-SA HSA, Archer MSA, or Medicare Advantage MSA Information Form and Instruction	Modified
Attachment to Supporting Statement.doc Supplementary Document	2008-08-19
5498-SA - Supporting Statement.doc Supporting Statement A	2011-10-19

IC Document Collections

IC ID	Document Title	Status
18582	HSA, Archer MSA, or Medicare Advantage MSA Information Form and Instruction	Modified

ICR Details

OMB Control No: 1545-1518	ICR Reference No: 201110-1545-055
Status: Historical Active	Previous ICR Reference No: 200808-1545-019
Agency/Subagency: TREAS/IRS	Agency Tracking No: EC-1545-1518
Title: HSA, Archer MSA, or Medicare Advantage MSA Information
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/27/2011
	Date Received in OIRA: 11/28/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2014	36 Months From Approved	12/31/2011
Responses	52,217	0	41,105
Time Burden (Hours)	8,877	0	6,988
Cost Burden (Dollars)	0	0	0

---

Abstract: Section 220(h) requires trustees to report to the IRS and medical savings account holders contributions to and the year-end fair market value of any contributions made to a medical savings account (MSA). Congress requires Treasury to report to them the total contributions made to an MSA for the current tax year. Section 1201 of the Medicare prescription Drug, Improvement, and Modernization Act of 2003 (P.L. 108-173) created new Code section 223. Section 223(h) requires the reporting of contributions to and the year-end fair market value of health savings accounts for tax years beginning after December 31, 2003.

---

Authorizing Statute(s): US Code: 26 USC 223 Name of Law: Health savings accounts
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 43382	07/20/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 72034	11/21/2011
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
HSA, Archer MSA, or Medicare Advantage MSA Information	Form 5498-SA	HSA, Archer MSA, or Medicare Advantage MSA Information

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	52,217	41,105	0	0	11,112	0
Annual Time Burden (Hours)	8,877	6,988	0	0	1,889	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Change Due to Adjustment in Agency Estimate: The change to the paperwork burden previously approved by OMB is due to an increase in estimated responses. The total number of responses increased by 11,112 and the total annual burden increased by 1,889.

---

Annual Cost to Federal Government: $5,450

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/28/2011

---