Trustee or Issuer's Name and Address:

Principal Trust Company/Delaware Charter is the trustee of your account. This field shows our legal name (Delaware Charter Guarantee & Trust Company) and our mailing address.

Trustee’s or Issuer’s Federal ID No.:

Shows Principal Trust Company / Delaware Charter's taxpayers identification number.

Participant’s Social Security Number:

Shows your Social Security number used for tax identification purposes.

Archer MSA Contributions:

Shows Archer MSA contributions for 2011 through
April 17th of the current year. These contributions may be deductible on your Form 1040 or 1040A (U.S. Individual Tax Return).

Total Contributions:

Shows total contributions made in 2011. This includes total contributions made in 2011 for 2010. This also includes qualified HSA funding distributions (trustee-to-trustee transfers from an IRA to an HSA received by you during 2011).

Total HSA or Archer Contributions:

Shows the total employer and employee/self-employed contributions made to your HSA or Archer MSA during the period of January 1 through April 17th of this year that are attributable to the prior tax year.

Rollover Contributions:

Shows any rollover contributions you made to this Archer MSA after a distribution from another Archer MSA or shows any rollovers to this HSA from another HSA or Archer MSA. See Form 8853 or Form 8889 and their instructions on how to report distributions and rollovers.

Fair Market Value of Account:

Shows the fair market value of your HSA, Archer MSA, or M + C MSA at the end of the year.

Type of Account:

Shows the type of account being reported on this Form 5498-SA.

SEP Contributions:

Shows SEP contributions made in 2011, including contributions made in 2011 for 2010. If made by your employer, do not deduct on your income tax return. If you made the contributions as a self-employed person (or partner), they may be deductible. See Publication 560.

Roth IRA Contributions:

Shows Roth IRA contributions that you made in 2012 and through April 17, 2012. Do not deduct on your income tax return.

SIMPLE Contributions:

Shows SIMPLE contributions made in 2011, including contributions made in 2011 for 2010. If made by your employer, do not deduct on your income tax return. If you made the contributions as a self-employed person (or partner), they may be deductible. See Publication 560.

Required minimum distribution

If box is checked you are required to take a mandatory minimum distribution

Corrected Form 5498:

If this box is checked it indicates that a corrected Form 5498 was filed with the IRS. Corrections must be filed with the IRS as soon as possible after errors are discovered.

Copy B - For Participant:

Indicates this is Copy B of your Form 5498-SA for your records. Principal Trust Company/Delaware Charter files copy A with the IRS.

Account Number:

Shows the brokerage account number for your IRA.

Source – Product:

Shows internal routing number used to produce this form.