Information Collection

Distributions From an Archer MSA or Medicare+Choice MSA

IC 18577 under ICR 200811-1545-013 · OMB 1545-1517.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1545-1517 can be found here:

Documents and Forms

Document Name Document Type
Form 1099-SA Distributions From an Archer MSA or Medicare+Choice MSA Form
instructions.pdf Instruction
1099-SA Distributions From an HSA, Archer MSA or Medical Advanta 38471Y09.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Distributions From an Archer MSA or Medicare+Choice MSA	Agency IC Tracking Number:	ah-1517-013

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1099-SA	Distributions From an HSA, Archer MSA or Medical Advantage MSA.	38471Y09.pdf		Yes	Yes	Fillable Fileable
Instruction			instructions.pdf		No		Paper Only

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10,336	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 97 %

	Approved	Previously Approved
Annual Number of Responses for this IC	25,839	25,839
Annual IC Time Burden (Hours)	3,618	3,618
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.