Form 1099-SA, Distributions from HSA/MSA Instructions
This form contains 50 fields organized into 16 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Account number | ||
| Account number | Text |
Enter the account number associated with the recipient’s HSA, Archer MSA, or Medicare Advantage MSA as referenced by the payer/trustee.
|
| Account type (HSA / Archer MSA / MA MSA) | ||
| HSA | Checkbox |
Check this box if the distribution reported on this Form 1099-SA is from a Health Savings Account (HSA).
|
| Archer MSA | Checkbox |
Check this box if the distribution reported on this Form 1099-SA is from an Archer Medical Savings Account (Archer MSA).
|
| MA MSA | Checkbox |
Check this box if the distribution reported on this Form 1099-SA is from a Medicare Advantage Medical Savings Account (MA MSA).
|
| Account Type (HSA / Archer MSA / MA MSA) | ||
| HSA | Checkbox |
Check this box if the distribution reported on this Form 1099-SA is from a Health Savings Account (HSA).
|
| Archer MSA | Checkbox |
Check this box if the distribution reported on this Form 1099-SA is from an Archer Medical Savings Account (Archer MSA).
|
| MA MSA | Checkbox |
Check this box if the distribution reported on this Form 1099-SA is from a Medicare Advantage Medical Savings Account (MA MSA).
|
| Calendar year | ||
| Calendar Year (YY) | Text |
Enter the last two digits of the calendar year to which this form applies.
|
| Distribution Amounts | ||
| Gross distribution amount | Number |
Enter the total gross amount distributed from the account during the calendar year.
|
| Earnings on excess contributions | Number |
Enter the amount of earnings attributable to excess contributions that were distributed.
|
| FMV on date of death | Number |
Enter the account's fair market value on the account holder’s date of death.
|
| Distribution amounts and code | ||
| Gross distribution | Number |
Enter the total gross amount distributed from the account for the year.
|
| Earnings on excess contributions | Number |
Enter the amount of earnings included in the distribution that are attributable to excess contributions.
|
| Distribution code | Text |
Enter the distribution code that identifies the type of distribution reported.
|
| FMV on date of death | Number |
Enter the fair market value of the account on the date of death, if applicable.
|
| Distribution Amounts and Codes | ||
| Gross Distribution | Number |
Enter the total gross distribution amount paid from the account during the tax year.
|
| Earnings on Excess Contributions | Number |
Enter the earnings attributable to excess contributions distributed during the tax year.
|
| Distribution Code | Text |
Enter the code that identifies the type of distribution being reported.
|
| FMV on Date of Death | Number |
Enter the fair market value of the account on the date of death, if applicable.
|
| Distribution Code | ||
| Distribution code | Text |
Enter the distribution code that identifies the type of distribution reported on this Form 1099-SA.
|
| Form Status (Void/Corrected) and Tax Year | ||
| Tax Year (last two digits) | Text |
Enter the last two digits of the calendar year for which this Form 1099-SA is being issued.
|
| VOID | Checkbox |
Check this box if this Form 1099-SA is void (should be treated as canceled and not processed).
|
| CORRECTED | Checkbox |
Check this box if this Form 1099-SA is a corrected version being issued to replace a previously filed form.
|
| Form Status and Tax Year | ||
| Tax Year (YY) | Text |
Enter the last two digits of the calendar year this Form 1099-SA applies to.
|
| CORRECTED (if checked) | Checkbox |
Check this box if this form is being filed to correct information reported on a previously issued Form 1099-SA.
|
| Form status flags (Void/Corrected) | ||
| VOID | Checkbox |
Check this box if this form is being marked void (invalid) and should be disregarded.
|
| CORRECTED | Checkbox |
Check this box if this form is a corrected version being issued to replace a previously filed form.
|
| Recipient information | ||
| Recipient TIN | Text |
Enter the recipient’s taxpayer identification number (TIN).
|
| Recipient Name | Text |
Enter the full legal name of the recipient.
|
| Recipient Street Address | Text |
Enter the recipient’s street address, including apartment or unit number if applicable.
|
| Recipient City/State/ZIP | Text |
Enter the recipient’s city or town, state or province, country (if applicable), and ZIP or foreign postal code.
|
| Recipient Information | ||
| Recipient TIN | Text |
Enter the recipient’s taxpayer identification number (TIN), such as an SSN, ITIN, or EIN.
|
| Recipient Name | Text |
Enter the full legal name of the recipient.
|
| Recipient Street Address | Text |
Enter the recipient’s street address, including apartment or suite number if applicable.
|
| Recipient City, State/Province, Country, ZIP/Postal Code | Text |
Enter the recipient’s city or town, state or province, country, and ZIP or foreign postal code.
|
| Account Number | Text |
Enter the recipient’s account number associated with this distribution, if applicable.
|
| Recipient TIN | Text |
Enter the recipient’s taxpayer identification number (TIN).
|
| Recipient Name | Text |
Enter the recipient’s full legal name.
|
| Recipient Street Address | Text |
Enter the recipient’s street address, including apartment or suite number if applicable.
|
| Recipient City, State, ZIP, Country | Text |
Enter the recipient’s city or town, state or province, country (if applicable), and ZIP or foreign postal code.
|
| Account Number | Text |
Enter the account number associated with the recipient, if provided for this form.
|
| Trustee/Payer information | ||
| Trustee/Payer name and address | Text |
Enter the trustee’s or payer’s full name and mailing address, including street, city, state or province, country, ZIP or foreign postal code, and telephone number.
|
| Payer's TIN | Text |
Enter the payer’s Taxpayer Identification Number (TIN).
|
| Trustee/Payer Information | ||
| Trustee/Payer Name and Address | Text |
Enter the trustee’s or payer’s full name and mailing address, including street address, city, state or province, country, postal code, and telephone number.
|
| Payer TIN | Text |
Enter the trustee’s or payer’s taxpayer identification number (TIN).
|
| Trustee/Payer Name and Address | Text |
Enter the trustee/payer’s full name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone number.
|
| Payer TIN | Text |
Enter the trustee/payer’s taxpayer identification number (TIN).
|
| Type of Account (Select One) | ||
| HSA | Checkbox |
Check this box if the distribution reported on this form is from a Health Savings Account (HSA).
|
| Archer MSA | Checkbox |
Check this box if the distribution reported on this form is from an Archer Medical Savings Account (Archer MSA).
|
| MA MSA (Medicare Advantage MSA) | Checkbox |
Check this box if the distribution reported on this form is from a Medicare Advantage Medical Savings Account (MA MSA).
|