Form 1099-SA Distributions From an HSA, Archer MSA or Medical Advanta

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CORRECTED

TRUSTEE'S/PAYER'S name, street address, city or town, state or province,
country, ZIP or foreign postal code, and telephone number

OMB No. 1545-1517

2015
Form 1099-SA
PAYER'S federal identification number

RECIPIENT'S identification number

RECIPIENT'S name

1 Gross distribution

2 Earnings on excess cont.

$

$

3 Distribution code

4 FMV on date of death

$
Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code
Account number (see instructions)

Distributions
From an HSA,
Archer MSA, or
Medicare Advantage
MSA

5 HSA
Archer
MSA
MA
MSA

Copy A

For
Internal Revenue
Service Center

File with Form 1096.
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2015 General
Instructions for
Certain
Information
Returns.

1099-SA
Cat. No. 38471D
www.irs.gov/form1099sa
Department of the Treasury - Internal Revenue Service
Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page

Form

CORRECTED (if checked)
TRUSTEE'S/PAYER'S name, street address, city or town, state or province,
country, ZIP or foreign postal code, and telephone number

OMB No. 1545-1517

2015
Form 1099-SA

Distributions
From an HSA,
Archer MSA, or
Medicare Advantage
MSA

1 Gross distribution

2 Earnings on excess cont.

$

$

RECIPIENT'S name

3 Distribution code

4 FMV on date of death

Street address (including apt. no.)

5 HSA

PAYER'S federal identification number

RECIPIENT'S identification number

Copy B
For
Recipient

$

City or town, state or province, country, and ZIP or foreign postal code

Archer
MSA
MA
MSA

This information
is being furnished
to the Internal
Revenue Service.

Account number (see instructions)
Form

1099-SA

(keep for your records)

www.irs.gov/form1099sa

Department of the Treasury - Internal Revenue Service

Instructions for Recipient
Distributions from a health savings account (HSA), Archer Medical Savings
Account (MSA), or Medicare Advantage (MA) MSA are reported to you on Form
1099-SA. File Form 8853 or Form 8889 with your Form 1040 to report a
distribution from these accounts even if the distribution is not taxable. The payer
is not required to compute the taxable amount of any distribution.
An HSA or Archer MSA distribution is not taxable if you used it to pay qualified
medical expenses of the account holder and family or you rolled it over. An HSA may
be rolled over to another HSA; an Archer MSA may be rolled over to another Archer
MSA or an HSA. An MA MSA is not taxable if you used it to pay qualified medical
expenses of the account holder only. If you did not use the distribution from an HSA,
Archer MSA, or MA MSA to pay for qualified medical expenses, or in the case of an
HSA or Archer MSA, you did not roll it over, you must include the distribution in your
income (see Form 8853 or Form 8889). Also, you may owe a penalty.
You may repay a mistaken distribution from an HSA no later than April 15
following the first year you knew or should have known the distribution was a
mistake, providing the trustee allows the repayment.
For more information, see the Instructions for Form 8853 and the Instructions
for Form 8889. Also see Pub. 969.
Spouse beneficiary. If you inherited an Archer MSA or MA MSA because of the
death of your spouse, special rules apply. See the Instructions for Form 8853. If
you inherited an HSA because of the death of your spouse, see the Instructions
for Form 8889.
Estate beneficiary. If the HSA, Archer MSA, or MA MSA account holder dies
and the estate is the beneficiary, the fair market value (FMV) of the account on
the date of death is includible in the account holder’s gross income. Report the
amount on the account holder’s final income tax return.
Nonspouse beneficiary. If you inherited the HSA, Archer MSA, or MA MSA
from someone who was not your spouse, you must report as income on your

tax return the FMV of the account as of the date of death. Report the FMV on
your tax return for the year the account owner died even if you received the
distribution from the account in a later year. See the Instructions for Form 8853
or the Instructions for Form 8889. Any earnings on the account after the date of
death (box 1 minus box 4 of Form 1099-SA) are taxable. Include the earnings on
the “Other income” line of your tax return.
Account number. May show an account or other unique number the payer
assigned to distinguish your account.
Box 1. Shows the amount received this year. The amount may have been a
direct payment to the medical service provider or distributed to you.
Box 2. Shows the earnings on any excess contributions you withdrew from an
HSA or Archer MSA by the due date of your income tax return. If you withdrew
the excess, plus any earnings, by the due date of your income tax return, you
must include the earnings in your income in the year you received the
distribution even if you used it to pay qualified medical expenses. This amount is
included in box 1. Include the earnings on the “Other income” line of your tax
return. An excise tax of 6% for each tax year is imposed on you for excess
individual and employer contributions that remain in the account. See Form
5329, Additional Taxes on Qualified Plans (Including IRAs) and Other TaxFavored Accounts.
Box 3. These codes identify the distribution you received: 1—Normal
distribution; 2—Excess contributions; 3—Disability; 4—Death distribution other
than code 6; 5—Prohibited transaction; 6—Death distribution after year of death
to a nonspouse beneficiary.
Box 4. If the account holder died, shows the FMV of the account on the date of
death.
Box 5. Shows the type of account that is reported on this Form 1099-SA.
Future developments. For the latest information about developments related to
Form 1099-SA and its instructions, such as legislation enacted after the form
and instructions were published, go to www.irs.gov/form1099sa.

VOID

CORRECTED

TRUSTEE'S/PAYER'S name, street address, city or town, state or province,
country, ZIP or foreign postal code, and telephone number

OMB No. 1545-1517

2015
Form 1099-SA
PAYER'S federal identification number

RECIPIENT'S identification number

RECIPIENT'S name

1 Gross distribution

2 Earnings on excess cont.

$

$

3 Distribution code

4 FMV on date of death

$
5 HSA

Street address (including apt. no.)
City or town, state or province, country, and ZIP or foreign postal code

Archer
MSA
MA
MSA

Account number (see instructions)
Form

1099-SA

Distributions
From an HSA,
Archer MSA, or
Medicare Advantage
MSA

www.irs.gov/form1099sa

Copy C
For
Trustee/Payer
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2015 General
Instructions for
Certain
Information
Returns.

Department of the Treasury - Internal Revenue Service

Instructions for Trustee/Payer
To complete Form 1099-SA, use:
• the 2015 General Instructions for Certain Information
Returns, and
• the 2015 Instructions for Forms 1099-SA and 5498-SA.
To order these instructions and additional forms, go to
www.irs.gov/form1099sa or call 1-800-TAX-FORM
(1-800-829-3676).
Caution. Because paper forms are scanned during
processing, you cannot file Forms 1096, 1097, 1098, 1099,
3921, 3922, or 5498 that you print from the IRS website.
Due dates. Furnish Copy B of this form to the recipient by
February 1, 2016.

File Copy A of this form with the IRS by February 29, 2016.
If you file electronically, the due date is March 31, 2016. To file
electronically, you must have software that generates a file
according to the specifications in Pub. 1220, Specifications for
Electronic Filing of Forms 1097, 1098, 1099, 3921, 3922,
5498, and W-2G. The IRS does not provide a fill-in form
option.
Need help? If you have questions about reporting on Form
1099-SA, call the information reporting customer service site
toll free at 1-866-455-7438 or 304-263-8700 (not toll free).
Persons with a hearing or speech disability with access to
TTY/TDD equipment can call 304-579-4827 (not toll free).