5498-SA CORRECTION VALIDATION RECORD
Account Reference:
Tax Year:
Original File Date:
Corrected File Date:

1. SOURCE DATA REVIEW
[ ] Correction reason identified and documented.
[ ] Transaction date and designation verified in ledger.
[ ] Internal approval obtained for data alteration.

2. FIELD RECONCILIATION (Original vs Corrected)
[ ] Participant TIN/Name: ______________________
[ ] Box 1 (Archer MSA only): ___________________
[ ] Box 2 (Total made in year): ________________
[ ] Box 3 (Subsequent year deposits): __________
[ ] Box 4 (Rollovers): _________________________
[ ] Box 5 (FMV on Dec 31): _____________________
[ ] Account Type Checkbox (HSA/MSA): ___________

3. COMPLIANCE AND TRANSMISSION
[ ] Unintended field changes identified and reversed (if any).
[ ] Mistaken distribution repayments excluded from Box 2/3.
[ ] Trustee-to-trustee transfers excluded from Box 4.
[ ] Correction indicator properly set in electronic file.
[ ] IRS transmission channel selected (IRIS).
[ ] Truncated payee statement generated for furnishing.

Preparer Signature: __________________ Date: _______
Reviewer Signature: __________________ Date: _______