Information Collection

Form 1099-SA - Distributions From an HSA, Archer MSA, or Medicare Advantage MSA

IC 18577 under ICR 202107-1545-012 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Form 1099-SA - Distributions From an HSA, Archer MSA, or Medicare Advantage MSA	Form
Form 1099-SA Distributions From an HSA, Archer MSA or Medical Advantage MSA Form 1099-SA - Distributions From an HSA, Archer MSA, or Medicare Advantage MSA	Form
Instr for Form 1099-SA_and_5498_SA--2021-00-00.pdf	Instruction
Instr for Form 1099-SA_and_5498_SA--2021-00-00.pdf	Instruction
1099-SA Distributions From an HSA, Archer MSA or Medical Advanta Form 1099-SA--2019-11-00.pdf	Form
1099-SA Distributions From an HSA, Archer MSA or Medical Advanta Form 1099-SA--2019-11-00.pdf	Form

IC Title:

Form 1099-SA - Distributions From an HSA, Archer MSA, or Medicare Advantage MSA

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

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				Yes	Yes	Fillable Fileable
Instruction					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
No associated records found

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

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