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

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FILE: 38471y09_a02.g
PRINTED: Fri Jun 27 07:49:38 2008
CREATED: Fri Jun 27 07:49:38 2008

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Page 1 of 6 of Form 1099-SA (Page 2 is Blank)

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scan organization

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reproduction proofs. MUST be removed before printing.

Date

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Separation 1—INK: Red, J-6983
Separation 2—INK: Black

9494

VOID

CORRECTED

TRUSTEE’S/PAYER’S name, street address, city, state, and ZIP code

OMB No. 1545-1517

2009

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a
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D /09
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PAYER’S federal identification number

RECIPIENT’S identification number

1

Gross distribution

$

RECIPIENT’S name

3

Distribution code

Street address (including apt. no.)

5

HSA
Archer
MSA

City, state, and ZIP code

MA
MSA

Account number (see instructions)

Form 1099-SA

Cat. No. 38471D

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Form 1099-SA

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

2 Earnings on excess cont.

$
4 FMV on date of death

$

Copy A
For
Internal Revenue
Service Center
File with Form 1096.
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2009 General
Instructions for
Forms 1099, 1098,
5498, and W-2G.

Department of the Treasury - Internal Revenue Service

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