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

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9494

VOID

CORRECTED

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

OMB No. 1545-1517

2012
Form 1099-SA
PAYER'S federal identification number

RECIPIENT'S name

RECIPIENT'S identification number

1 Gross distribution

2 Earnings on excess cont.

$

$

3 Distribution code

4 FMV on date of death

$
Street address (including apt. no.)
City, state, and ZIP 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
2012 General
Instructions for
Certain
Information
Returns.

1099-SA
Cat. No. 38471D
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, state, and ZIP code

OMB No. 1545-1517

2012
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, state, and ZIP 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)

Department of the Treasury - Internal Revenue Service

Instructions for Recipient
Distributions from a health savings account (HSA), Archer 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.
For more information, see the separate instructions for Form 8853 and Form
8889. Also see Pub. 969.
Recipient's identification number. For your protection, this form may show
only the last four digits of your social security number (SSN), individual taxpayer
identification number (ITIN), or adoption taxpayer identification number (ATIN).
However, the issuer has reported your complete identification number to the
IRS, and, where applicable, to state and/or local governments.
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 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.

VOID

CORRECTED

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

OMB No. 1545-1517

2012
Form 1099-SA
PAYER'S federal identification number

RECIPIENT'S name

RECIPIENT'S identification number

1 Gross distribution

2 Earnings on excess cont.

$

$

3 Distribution code

4 FMV on date of death

$
Street address (including apt. no.)
City, state, and ZIP code
Account number (see instructions)
Form

1099-SA

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

5 HSA
Archer
MSA
MA
MSA

Copy C
For
Trustee/Payer
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2012 General
Instructions for
Certain
Information
Returns.

Department of the Treasury - Internal Revenue Service

Instructions for Trustee/Payer
General and specific form instructions are provided as
separate products. The products you should use to
complete Form 1099-SA are the 2012 General
Instructions for Certain Information Returns and the
2012 Instructions for Forms 1099-SA and 5498-SA. A
chart in the general instructions gives a quick guide to
which form must be filed to report a particular payment.
To order these instructions and additional forms, visit
IRS.gov 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 January 31, 2013.

File Copy A of this form with the IRS by
February 28, 2013. If you file electronically, the due date
is April 1, 2013. To file electronically, you must have
software that generates a file according to the
specifications in Pub. 1220, Specifications for Filing
Forms 1097, 1098, 1099, 3921, 3922, 5498, 8935, and
W-2G Electronically. 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). For TTY/TDD equipment, call
304-579-4827 (not toll free). The hours of operation are
Monday through Friday from 8:30 a.m. to 4:30 p.m.,
Eastern time.