Distributions From an Archer MSA or Medicare+Choice MSA

Forms and Documents

Document Name	Status
Form 1099-SA Distributions From an Archer MSA or Medicare+Choice MSA Form	Modified
1099-MSA.Supporting Statement.doc Supporting Statement A	2015-04-22

IC Document Collections

IC ID	Document Title	Status
18577	Distributions From an Archer MSA or Medicare+Choice MSA Form	Modified

ICR Details

OMB Control No: 1545-1517	ICR Reference No: 201503-1545-001
Status: Historical Active	Previous ICR Reference No: 201201-1545-011
Agency/Subagency: TREAS/IRS	Agency Tracking No:
Title: Distributions From an Archer MSA or Medicare+Choice MSA
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/05/2015
	Date Received in OIRA: 04/30/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2018	36 Months From Approved	10/31/2015
Responses	25,839	0	25,839
Time Burden (Hours)	3,618	0	3,618
Cost Burden (Dollars)	0	0	0

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Abstract: This form is used to report distributions from a medical savings account as set forth in section 220(h).

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Authorizing Statute(s): US Code: 26 USC 220(h) Name of Law: Reports
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 7529	02/10/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 24317	04/30/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Distributions From an Archer MSA or Medicare+Choice MSA	1099-SA	Distributions From an HSA, Archer MSA or Medical Advantage MSA

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	25,839	25,839	0	0	0	0
Annual Time Burden (Hours)	3,618	3,618	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $4,599

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/30/2015

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