Form 1099-SA, Distributions from HSA/MSA Instructions
This form contains 50 fields organized into 11 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Account Information | ||
| Account number (see instructions) | Text |
Enter the account number associated with the distribution. Refer to the instructions for more details.
|
| Account number (see instructions) | Text |
Enter the account number associated with the distribution, as per the instructions provided.
|
| Account number (see instructions) | Text |
Enter the account number associated with the Health Savings Account (HSA), Archer MSA, or Medicare Advantage MSA. Refer to the instructions for more details.
|
| Additional Information | ||
| Text |
Provide any additional information or details as required by the form instructions.
|
|
| Distribution Codes | ||
| Form1099-SA[0].CopyC[0].RightCol[0].c1_2[0]_1 | CheckBox |
Check this box if the distribution was made for qualified medical expenses.
|
| Form1099-SA[0].CopyC[0].RightCol[0].c1_2[1]_2 | CheckBox |
Check this box if the distribution was made for non-qualified expenses.
|
| Form1099-SA[0].CopyC[0].RightCol[0].c1_2[2]_3 | CheckBox |
Check this box if the distribution was made due to death or disability.
|
| Distribution Details | ||
| Number |
Enter the gross distribution amount from the HSA, Archer MSA, or Medicare Advantage MSA.
|
|
| 3 Distribution code | Text |
Enter the distribution code that identifies the type of distribution made from the account.
|
| Number |
Enter the earnings on excess contributions distributed from the account.
|
|
| Form1099-SA[0].CopyB[0].RightCol[0].c1_2[0]_1 | CheckBox |
Check this box if the distribution was made for qualified medical expenses.
|
| Form1099-SA[0].CopyB[0].RightCol[0].c1_2[1]_2 | CheckBox |
Check this box if the distribution was not used for qualified medical expenses.
|
| Form1099-SA[0].CopyB[0].RightCol[0].c1_2[2]_3 | CheckBox |
Check this box if the distribution was made after the account holder's death.
|
| 1 | Number |
Enter the gross distribution amount from the HSA, Archer MSA, or Medicare Advantage MSA.
|
| Number |
Enter any earnings on excess contributions distributed from the account.
|
|
| 3 | Text |
Enter the distribution code that applies to the distribution. Refer to the form instructions for the correct code.
|
| Number |
Enter the fair market value of the account on the date of death, if applicable.
|
|
| Distribution Information | ||
| 1 Gross distribution | Number |
Enter the total gross distribution amount from the account for the year.
|
| 3 Distribution code | Text |
Enter the distribution code that corresponds to the type of distribution made. Refer to the form instructions for the correct code.
|
| 4 FMV on date of death | Number |
Enter the fair market value of the account on the date of the account holder's death, if applicable.
|
| Form Details | ||
| 20 | Text |
Enter the tax year for which this Form 1099-SA is being filed. Use a two-digit format (e.g., '20' for 2020).
|
| Form Information | ||
| 20 | Text |
Enter the year for which the Form 1099-SA is being filed. This should be a two-digit year, such as '21' for 2021.
|
| Form1099-SA[0].CopyA[0].CopyAHeader[0].c1_1[0]_1 | CheckBox |
Check this box if the form is a corrected version of a previously filed Form 1099-SA.
|
| Form1099-SA[0].CopyA[0].CopyAHeader[0].c1_1[1]_2 | CheckBox |
Check this box if the form is a void version, indicating that the form should not be processed.
|
| 20 | Text |
Enter the tax year for which this form is being filed. Use a two-digit format (e.g., '20' for 2020).
|
| Form1099-SA[0].CopyC[0].CopyCHeader[0].c1_1[0]_1 | CheckBox |
Check this box if this is a corrected form.
|
| Form1099-SA[0].CopyC[0].CopyCHeader[0].c1_1[1]_2 | CheckBox |
Check this box if this is an amended form.
|
| General Information | ||
| Form1099-SA[0].CopyA[0].RightCol[0].c1_2[0]_1 | CheckBox |
Indicate whether this checkbox is applicable for the specific condition it represents on the form.
|
| Form1099-SA[0].CopyA[0].RightCol[0].c1_2[1]_2 | CheckBox |
Indicate whether this checkbox is applicable for the specific condition it represents on the form.
|
| Form1099-SA[0].CopyA[0].RightCol[0].c1_2[2]_3 | CheckBox |
Indicate whether this checkbox is applicable for the specific condition it represents on the form.
|
| Form1099-SA[0].CopyB[0].CopyBHeader[0].c1_1[0]_2 | CheckBox |
Indicate whether this checkbox is applicable for the specific condition it represents on the form.
|
| Payer Information | ||
| TRUSTEE'S/PAYER'S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone number | Text |
Enter the name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone number of the trustee or payer.
|
| PAYER'S TIN | Text |
Enter the Taxpayer Identification Number (TIN) of the payer. This is typically a 9-digit number.
|
| TRUSTEE'S/PAYER'S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone number | Text |
Enter the name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone number of the trustee or payer.
|
| PAYER'S TIN | Text |
Enter the Taxpayer Identification Number (TIN) of the payer. This should be a 9-digit number.
|
| TRUSTEE'S/PAYER'S name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone number | Text |
Enter the trustee's or payer's full name, address, and contact information.
|
| PAYER'S TIN | Text |
Enter the payer's Taxpayer Identification Number (TIN).
|
| Recipient Information | ||
| RECIPIENT'S TIN | Text |
Enter the Taxpayer Identification Number (TIN) of the recipient. This is typically a 9-digit number.
|
| RECIPIENT'S name | Text |
Enter the full name of the recipient of the distribution.
|
| Street address (including apt. no.) | Text |
Enter the street address of the recipient, including apartment number if applicable.
|
| City or town, state or province, country, and ZIP or foreign postal code | Text |
Enter the city or town, state or province, country, and ZIP or foreign postal code of the recipient.
|
| RECIPIENT'S TIN | Text |
Enter the Taxpayer Identification Number (TIN) of the recipient. This should be a 9-digit number.
|
| RECIPIENT'S name | Text |
Enter the full name of the recipient of the distribution.
|
| Street address (including apt. no.) | Text |
Enter the street address of the recipient, including apartment number if applicable.
|
| b17f City or town, state or province, country, and ZIP or foreign postal code | Text |
Enter the city or town, state or province, country, and ZIP or foreign postal code of the recipient.
|
| RECIPIENT'S TIN | Text |
Enter the recipient's Taxpayer Identification Number (TIN).
|
| RECIPIENT'S name | Text |
Enter the full name of the recipient.
|
| Street address (including apt. no.) | Text |
Enter the street address, including apartment number if applicable, of the recipient of the distribution.
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| 2ddd City or town, state or province, country, and ZIP or foreign postal code | Text |
Enter the city or town, state or province, country, and ZIP or foreign postal code of the recipient's address.
|
| Unlabeled Field | ||
| Text |
This field is not labeled. Please refer to the form instructions or context for its intended use.
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