May 19th, 2015
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FormOMB No. 1545-00748889Department of the TreasuryInternal Revenue ServiceHealth Savings Accounts (HSAs)Attach to Form 1040 or Form 1040NR.Social security number of HSAbeneficiary. If both spouses haveHSAs, see the instructionsName(s) shown on Form 1040 or Form 1040NRSarahPetersan2010AttachmentSequence No.See separate instructions.53001-02-0000Before you begin: Complete Form 8853, Archer MSAs and Long-Term Care Insurance Contracts, if required.Part I12345678910111213HSA Contributions and Deduction. See the instructions before completing t

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