Form 1099-SA, Distributions From an HSA, Archer MSA, or Medicare Advantage MSA Completed Form Examples and Samples
Explore practical examples and samples of Form 1099-SA, Distributions From an HSA, Archer MSA, or Medicare Advantage MSA. Learn how to accurately fill out your tax forms with our detailed guides.
Automated Processing of Form 1099-SA for HSA Distributions
How this form was filled:
This example demonstrates how an AI can accurately extract sensitive financial data from a standard account statement email. By parsing the unstructured narrative, the system automatically populates the required fields for Form 1099-SA, streamlining tax compliance for health savings account distributions.
Source document used: Tax Reporting Notification Email
Subject: Your 2026 Tax Documents for HSA Account #88921-X. Dear Sarah Jenkins, we are writing to provide your tax reporting information for your Health Savings Account held with Blue Shield Financial Trust, located at 4500 Banking Plaza, Chicago, IL 60601. You can reach our tax reporting department at 800-555-0199 for any questions regarding this statement. For the 2026 calendar year, our records indicate a gross distribution of $4,250.00 from your HSA. Please note that $120.00 of this amount is categorized as earnings on excess contributions. The distribution code associated with this transaction is 1, indicating a normal distribution. As this was a standard HSA distribution, no fair market value on the date of death is applicable for this filing. We have reported this information to the IRS under our Payer TIN 12-3456789. The recipient, Sarah Jenkins, residing at 12 Maple Street, Apartment 4B, Springfield, IL 62704, with TIN 987-65-4321, should retain this for her personal tax records. Please remember that if you have questions about filing, you should consult IRS Form 8889. Thank you for choosing Blue Shield Financial Trust for your health savings needs.
Information used to fill out the document:
- Trustee: Blue Shield Financial Trust, 4500 Banking Plaza, Chicago, IL 60601
- Recipient: Sarah Jenkins, 12 Maple Street, Apt 4B, Springfield, IL 62704
- Tax Year: 2026
- Account Numbers: Payer TIN: 12-3456789, Recipient TIN: 987-65-4321, Account: 88921-X
- Distributions: Gross: $4,250.00, Earnings: $120.00, Code: 1
- Account Type: HSA
What this filled form sample shows:
- Automatic identification of Payer vs Recipient addresses
- Intelligent mapping of unstructured monetary values to specific IRS boxes
- Filtering of irrelevant conversational filler from technical financial data
- Detection of account type (HSA) from context
- Normalization of TIN formats and numeric identifiers
Form specifications and details:
| Form Name: | 1099-SA |
| Reporting Purpose: | Distributions From an HSA, Archer MSA, or Medicare Advantage MSA |
| Tax Year: | 2026 |
| Compliance Level: | IRS Standard |
| Categories: | CAR forms, distribution forms, HSA forms, Medicare forms, 1099 forms, L.A. Care forms |
| Created: | May 18, 2026 06:40 PM |