Information Collection

Distributions From an Archer MSA or Medicare+Choice MSA

IC 18577 under ICR 201503-1545-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form 1099-SA Distributions From an Archer MSA or Medicare+Choice MSA	Form
Form 1099-SA Instructions.pdf	Instruction
1099-SA Distributions From an HSA, Archer MSA or Medical Advanta Form 1099-SA.pdf	Form
1099-SA burden.PDF Burden	IC Document

IC Title:

Distributions From an Archer MSA or Medicare+Choice MSA

Agency IC Tracking Number:

1545-1517

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 26 CFR 301.6109-4

Information Collection Instruments:

table that charts list of 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	Form 1099-SA.pdf		Yes	Yes	Fillable Fileable
Instruction			Form 1099-SA Instructions.pdf		Yes	No	Printable 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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
Burden	1099-SA burden.PDF	01/24/2012

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