Fill and Sign the Multistate Riders and Addenda Form 3183 Single Family Fannie Mae Uniform Instrument

Health Savings Account (HSA) Understanding IRS Form 5498-SA for your Wells Fargo Health Savings Account (HSA) The Internal Revenue Service (IRS) requires Wells Fargo to issue Form 5498-SA if you had any contribution activity in your Wells Fargo HSA during the previous tax year. You’ll find a description of each of the fields on the form below. Refer to the Frequently Asked Questions on the next page for more helpful information about HSA tax forms and filing. •• Box 1 – Employee or self-employed person’s Archer MSA contributions made in the tax year: This box relates to an Archer MSA and is not used by Wells Fargo. •• Box 2 – Total contributions made: This box contains the total contributions made in the tax year, including IRA to HSA transfers. •• Box 3 – Total HSA or Archer MSA contributions made in the tax year: This box contains the total HSA contributions made in in the current year for the prior tax year. •• Box 4 – Rollover contributions: This box contains the HSA, MSA, FSA, and HRA rollover contributions to the HSA received by Wells Fargo Health Benefit Services (HBS) in the tax year. •• Box 5 – Fair market value of HSA, Archer MSA, or MA MSA: This box contains the Fair Market Value (FMV) of the HSA on Dec. 31, at the end of the calendar year. •• Box 6 – HSA, Archer MSA, MA MSA: This shows the type of account that is reported on this Form 5498-SA. continued Frequently Asked Questions Q: Why did I receive Form 5498-SA? Q: How is a rollover to my Wells Fargo HSA reported? A: The IRS requires Wells Fargo to issue Form 5498-SA if you had any contribution activity in your Wells Fargo HSA during the previous tax year. The information on the 5498SA has been submitted to the IRS. You’re receiving this form for your records only. A: An HSA rollover is reported in Box 4 on Form 5498-SA. Rollover amounts are not counted toward the maximum annual contribution limit. Q: How do I know what the current maximum annual contribution limit is for my Wells Fargo HSA? A: If you transferred your HSA to a Wells Fargo HSA the Form 5498-SA issued by Wells Fargo only includes contribution and rollover activity from the time the account was first transferred to Wells Fargo. Your former HSA record keeper should provide a Form 5498-SA for any contribution/rollover activity that occurred before your account was transferred. A: Provided that you are considered an eligible individual for the entire year, the maximum annual amount that can be contributed to an HSA from all sources (employer, employee, and other third-party contributions) is $3,100 for individual coverage and $6,250 for family coverage1. In addition, if you are at least age 55, are not enrolled in Medicare and otherwise are an eligible individual, you may elect to make additional catch-up contributions to your HSA. The current maximum catch-up contribution amount is $1,000. Consult your tax advisor for more information about how the contribution limits apply to your situation. Q: How do I handle excess contributions to my Wells Fargo HSA? A: Amounts contributed to your HSA that exceed your maximum annual contribution amount are considered excess contributions and are not deductible. Generally, you must pay a 6 percent excise tax on excess contributions. See IRS Form 5329 “Additional Taxes on Qualified Plans (Including IRAs) and Other Tax-Favored Accounts,” to figure the excise tax. To avoid the 6 percent excise tax, you must withdraw the excess contributions and any applicable earnings by the due date, including extensions, of your tax return for the year the contributions were made. 1 The 2012 contribution limits are $3,100 for individuals and $6,250 for families wellsfargo.com/hsa Health Benefit Services, A Division of Wells Fargo Bank, N.A. © 2011 Wells Fargo Bank, N.A. All rights reserved MC-1635 - 08/11 Q: I transferred my HSA to Wells Fargo. Who will send me my tax forms? Q: Who do I contact if I have questions about HSA tax forms and filing information? A: Contact your tax advisor if you have questions about HSA tax forms and filing.