Form 1099-SA, Distributions From an HSA, Archer MSA, or Medicare Advantage MSA Instructions

Please enter the account number associated with this form.

Check this box if the distribution is from a Health Savings Account (HSA).

Check this box if the distribution is from an Archer Medical Savings Account (MSA).

Check this box if the distribution is from a Medicare Advantage Medical Savings Account (MA MSA).

Check this box if the distribution is from a Health Savings Account (HSA).

Check this box if the distribution is from an Archer Medical Savings Account (MSA).

Check this box if the distribution is from a Medicare Advantage Medical Savings Account (MA MSA).

Please provide the calendar year for which this form applies.

Enter the four-digit calendar year for which this form is being filed.

Check this box if this is a corrected Form 1099-SA.

Please provide the distribution code for this transaction.

Enter the total amount of the gross distribution.

Enter the amount of earnings on excess contributions.

Enter the code that identifies the type of distribution.

Enter the fair market value (FMV) of the account on the date of death. Fill only if 'Distribution code' indicates a death distribution.

Provide the total amount of earnings on excess contributions.

Enter the fair market value on the date of death if applicable. This value reflects the account’s market value on the date of the recipient’s death. Fill only if 'Distribution Code' Distribution code is for a death distribution (e.g., code 4 or 6).

This checkbox in the header section helps designate a specific copy option. Select it if the corresponding copy requirement is met.

Check this box if this form is a corrected version of a previously filed form.

Please provide the total amount of the gross distribution.

Please enter the trustee's or payer's full name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone number.

Please enter the Payer's Taxpayer Identification Number (TIN).

Enter the recipient's Taxpayer Identification Number (TIN). Usually, it should be a 9-digit identifier.

Provide the recipient's full legal name exactly as it appears on official records.

Enter the recipient's street address, including the apartment number if applicable.

Provide the recipient's city or town, state or province, country, and ZIP or foreign postal code.

Enter the account number for the HSA, Archer MSA, or Medicare Advantage MSA. Refer to the instructions if you are unsure of the correct number.

Please provide the full name of the recipient.

Please provide the street address of the recipient, including apartment, suite, or unit number if applicable.

Please provide the city, town, state or province, country, and ZIP or foreign postal code of the recipient's address.

Provide the Taxpayer Identification Number (TIN) for the recipient.

Enter the trustee's or payer's full name, street address, city or town, state or province, country, ZIP or foreign postal code, and telephone number.

Enter the Taxpayer Identification Number (TIN) for the payer.