IRS Form 1099-SA "Distributions From an Hsa, Archer Msa, or Medicare Advantage Msa"

What Is IRS Form 1099-SA?

This is a tax form that was released by the Internal Revenue Service (IRS) - a subdivision of the U.S. Department of the Treasury. Check the official IRS-issued instructions before completing and submitting the form.

Form Details:

  • A 5-page form available for download in PDF;
  • Actual and valid for filing 2020 taxes;
  • Editable, printable, and free;

Download a fillable version of IRS Form 1099-SA through the link below or browse more documents in our library of IRS Forms.

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Download IRS Form 1099-SA "Distributions From an Hsa, Archer Msa, or Medicare Advantage Msa"

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VOID
CORRECTED
9494
TRUSTEE'S/PAYER'S name, street address, city or town, state or province,
OMB No. 1545-1517
Distributions
country, ZIP or foreign postal code, and telephone number
From an HSA,
2019
Archer MSA, or
Medicare Advantage
MSA
1099-SA
Form
Copy A
PAYER'S TIN
RECIPIENT'S TIN
1 Gross distribution
2 Earnings on excess cont.
For
$
$
Internal Revenue
RECIPIENT'S name
3 Distribution code
4 FMV on date of death
Service Center
File with Form 1096.
$
For Privacy Act
and Paperwork
Street address (including apt. no.)
5 HSA
Reduction Act
Archer
Notice, see the
MSA
2019 General
City or town, state or province, country, and ZIP or foreign postal code
MA
Instructions for
MSA
Certain
Account number (see instructions)
Information
Returns.
1099-SA
Form
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
VOID
CORRECTED
9494
TRUSTEE'S/PAYER'S name, street address, city or town, state or province,
OMB No. 1545-1517
Distributions
country, ZIP or foreign postal code, and telephone number
From an HSA,
2019
Archer MSA, or
Medicare Advantage
MSA
1099-SA
Form
Copy A
PAYER'S TIN
RECIPIENT'S TIN
1 Gross distribution
2 Earnings on excess cont.
For
$
$
Internal Revenue
RECIPIENT'S name
3 Distribution code
4 FMV on date of death
Service Center
File with Form 1096.
$
For Privacy Act
and Paperwork
Street address (including apt. no.)
5 HSA
Reduction Act
Archer
Notice, see the
MSA
2019 General
City or town, state or province, country, and ZIP or foreign postal code
MA
Instructions for
MSA
Certain
Account number (see instructions)
Information
Returns.
1099-SA
Form
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
CORRECTED (if checked)
TRUSTEE'S/PAYER'S name, street address, city or town, state or province,
OMB No. 1545-1517
Distributions
country, ZIP or foreign postal code, and telephone number
From an HSA,
2019
Archer MSA, or
Medicare Advantage
MSA
1099-SA
Form
Copy B
PAYER'S TIN
RECIPIENT'S TIN
1 Gross distribution
2 Earnings on excess cont.
$
$
For
Recipient
RECIPIENT'S name
3 Distribution code
4 FMV on date of death
$
Street address (including apt. no.)
5 HSA
Archer
This information
MSA
is being furnished
City or town, state or province, country, and ZIP or foreign postal code
MA
to the IRS.
MSA
Account number (see instructions)
1099-SA
(keep for your records)
Form
www.irs.gov/Form1099SA
Department of the Treasury - Internal Revenue Service
Instructions for Recipient
Nonspouse beneficiary. If you inherited the HSA, Archer MSA, or MA MSA
from someone who wasn't your spouse, you must report as income on your tax
Distributions from a health savings account (HSA), Archer medical savings
return the FMV of the account as of the date of death. Report the FMV on your
account (MSA), or Medicare Advantage (MA) MSA are reported to you on
tax return for the year the account owner died even if you received the
Form 1099-SA. File Form 8853 or Form 8889 with your Form 1040 to report a
distribution from the account in a later year. See the Instructions for Form 8853
distribution from these accounts even if the distribution isn't taxable. The payer
or the Instructions for Form 8889. Any earnings on the account after the date of
isn't required to compute the taxable amount of any distribution.
death (box 1 minus box 4 of Form 1099-SA) are taxable. Include the earnings on
An HSA or Archer MSA distribution isn't taxable if you used it to pay qualified medical
the “Other income” line of your tax return.
expenses of the account holder or eligible family member or you rolled it over. An HSA
Account number. May show an account or other unique number the payer
may be rolled over to another HSA; an Archer MSA may be rolled over to another Archer
assigned to distinguish your account.
MSA or an HSA. An MA MSA isn't taxable if you used it to pay qualified medical
Box 1. Shows the amount received this year. The amount may have been a
expenses of the account holder only. If you didn't use the distribution from an HSA,
direct payment to the medical service provider or distributed to you.
Archer MSA, or MA MSA to pay for qualified medical expenses, or in the case of an HSA
Box 2. Shows the earnings on any excess contributions you withdrew from an HSA
or Archer MSA, you didn't roll it over, you must include the distribution in your income
or Archer MSA by the due date of your income tax return. If you withdrew the
(see Form 8853 or Form 8889). Also, you may owe a penalty.
excess, plus any earnings, by the due date of your income tax return, you must
You may repay a mistaken distribution from an HSA no later than April 15
include the earnings in your income in the year you received the distribution even if
following the first year you knew or should have known the distribution was a
you used it to pay qualified medical expenses. This amount is included in box 1.
mistake, providing the trustee allows the repayment.
Include the earnings on the “Other income” line of your tax return. An excise tax of
For more information, see the Instructions for Form 8853 and the Instructions
6% for each tax year is imposed on you for excess individual and employer
for Form 8889. Also see Pub. 969.
contributions that remain in the account. See Form 5329, Additional Taxes on
Recipient's taxpayer identification number (TIN). For your protection, this form
Qualified Plans (Including IRAs) and Other Tax-Favored Accounts.
may show only the last four digits of your TIN (SSN, ITIN, ATIN, or EIN). However,
Box 3. These codes identify the distribution you received: 1—Normal
the issuer has reported your complete identification number to the IRS.
distribution; 2—Excess contributions; 3—Disability; 4—Death distribution other
Spouse beneficiary. If you inherited an Archer MSA or MA MSA because of the death of
than code 6; 5—Prohibited transaction; 6—Death distribution after year of death
your spouse, special rules apply. See the Instructions for Form 8853. If you inherited an
to a nonspouse beneficiary.
HSA because of the death of your spouse, see the Instructions for Form 8889.
Box 4. If the account holder died, shows the FMV of the account on the date of death.
Estate beneficiary. If the HSA, Archer MSA, or MA MSA account holder dies
Box 5. Shows the type of account that is reported on this Form 1099-SA.
and the estate is the beneficiary, the fair market value (FMV) of the account on
Future developments. For the latest information about developments related to
the date of death is includible in the account holder’s gross income. Report the
Form 1099-SA and its instructions, such as legislation enacted after they were
amount on the account holder’s final income tax return.
published, go to www.irs.gov/Form1099SA.
VOID
CORRECTED
TRUSTEE'S/PAYER'S name, street address, city or town, state or province,
OMB No. 1545-1517
Distributions
country, ZIP or foreign postal code, and telephone number
From an HSA,
2019
Archer MSA, or
Medicare Advantage
MSA
1099-SA
Form
Copy C
PAYER'S TIN
RECIPIENT'S TIN
1 Gross distribution
2 Earnings on excess cont.
$
$
For
Trustee/Payer
RECIPIENT'S name
4 FMV on date of death
3 Distribution code
For Privacy Act
$
and Paperwork
Reduction Act
Street address (including apt. no.)
5 HSA
Notice, see the
Archer
2019 General
MSA
City or town, state or province, country, and ZIP or foreign postal code
Instructions for
MA
Certain
MSA
Information
Account number (see instructions)
Returns.
1099-SA
Form
www.irs.gov/Form1099SA
Department of the Treasury - Internal Revenue Service
Instructions for Trustee/Payer
To complete Form 1099-SA, use:
File Copy A of this form with the IRS by February 28, 2020.
If you file electronically, the due date is March 31, 2020. To file
• The 2019 General Instructions for Certain Information
electronically, you must have software that generates a file
Returns, and
according to the specifications in Pub. 1220.
• The 2019 Instructions for Forms 1099-SA and 5498-SA.
Need help? If you have questions about reporting on Form
To get or to order these instructions, go to
1099-SA, call the information reporting customer service site
www.irs.gov/Form1099SA.
toll free at 866-455-7438 or 304-263-8700 (not toll free).
Due dates. Furnish Copy B of this form to the recipient by
Persons with a hearing or speech disability with access to
January 31, 2020.
TTY/TDD equipment can call 304-579-4827 (not toll free).