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

OMB 1545-1517

OMB 1545-1517

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

The latest form for Distributions From an HSA, Archer MSA, or Medicare Advantage MSA expires 2021-12-31 and can be found here.

Latest Forms, Documents, and Supporting Material
Document
Name
Form
Supporting Statement A
All Historical Document Collections
Approved without change
 Extension without change of a currently approved collection 2021-12-31
Approved without change
 Extension without change of a currently approved collection 2018-10-30
Approved without change
 Extension without change of a currently approved collection 2015-04-30
Approved without change
 Extension without change of a currently approved collection 2012-01-30
Approved without change
 Extension without change of a currently approved collection 2008-11-26
Approved without change
 Extension without change of a currently approved collection 2005-09-22
Approved without change
 No material or nonsubstantive change to a currently approved collection 2004-03-17
Approved without change
 Revision of a currently approved collection 2002-09-11
Approved without change
 Extension without change of a currently approved collection 2000-04-24
Approved without change
 No material or nonsubstantive change to a currently approved collection 1998-09-15
Approved without change
 Extension without change of a currently approved collection 1997-03-27
Approved without change
 New collection (Request for a new OMB Control Number) 1996-12-18
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