5498-SA 3up Participant Copy B (9380)

HSA, ARCHER MSA, or Medicare Advantage MSA Information: Use this form to print and mail payment information to the participant. Forms are 3up format on 8 1/2" x 11" sheet with a 1/2" side perforation printed on 20# laser paper.

Details:

Order quantity equal to number of participants you are filing.

Compatible Envelopes: 99DWENV05, 99DWENVS05 (self seal)