Form 1099-SA

(Rev. November 2019)

Cat. No. 38471D

Distributions 

From an HSA, 

Archer MSA, or 

Medicare Advantage 

MSA

Copy A

For 

Internal Revenue 

Service Center

Department of the Treasury - Internal Revenue Service

File with Form 1096. 

OMB No. 1545-1517

For Privacy Act 

and Paperwork 

Reduction Act 

Notice, see the 

current General 

Instructions for 

Certain 

Information 

Returns.

For calendar year 

20

9494 VOID CORRECTED

TRUSTEE'S/PAYER’S name, street address, city or town, state or province, 

country, ZIP or foreign postal code, and telephone number

PAYER’S TIN RECIPIENT’S TIN

RECIPIENT’S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

Account number (see instructions)

1 Gross distribution

$

2 Earnings on excess cont.

$

3 Distribution code 4 FMV on date of death

$

5 HSA

Archer 

MSA

MA 

MSA

Form 1099-SA (Rev. 11-2019) www.irs.gov/Form1099SA

Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page
 

Form 1099-SA

(Rev. November 2019)

Distributions 

From an HSA, 

Archer MSA, or 

Medicare Advantage 

MSA

Copy B

For 

Recipient

Department of the Treasury - Internal Revenue Service

This information 

is being furnished 

to the IRS.

OMB No. 1545-1517

For calendar year 

20

CORRECTED (if checked)

TRUSTEE’S/PAYER’S name, street address, city or town, state or province, 

country, ZIP or foreign postal code, and telephone number

PAYER’S TIN RECIPIENT’S TIN

RECIPIENT’S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

Account number (see instructions)

1 Gross distribution

$

2 Earnings on excess cont.

$

3 Distribution code 4 FMV on date of death

$

5 HSA

Archer 

MSA

MA 

MSA

Form 1099-SA (Rev. 11-2019) (keep for your records) www.irs.gov/Form1099SA
Instructions for Recipient

Distributions from a health savings account (HSA), Archer medical savings 

account (MSA), or Medicare Advantage (MA) MSA are reported to you on 

Form 1099-SA. File Form 8853 or Form 8889 with your Form 1040 or 1040-SR 

to report a distribution from these accounts even if the distribution isn’t taxable. 

The payer isn’t required to compute the taxable amount of any distribution.

An HSA or Archer MSA distribution isn’t taxable if you used it to pay qualified medical 

expenses of the account holder or eligible family member 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 isn’t taxable if you used it to pay qualified medical 

expenses of the account holder only. If you didn’t 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 didn’t roll it over, you must include the distribution in your income 

(see Form 8853 or Form 8889). Also, you may owe a penalty.

You may repay a mistaken distribution from an HSA no later than April 15 

following the first year you knew or should have known the distribution was a 

mistake, providing the trustee allows the repayment.

For more information, see the Instructions for Form 8853 and the Instructions 

for Form 8889. Also see Pub. 969.

Recipient’s taxpayer identification number (TIN). For your protection, this form 

may show only the last four digits of your TIN (SSN, ITIN, ATIN, or EIN). However, 

the issuer has reported your complete identification number to the IRS.

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 wasn’t 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 the Instructions for 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 Tax-Favored 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.

Future developments. For the latest information about developments related to 

Form 1099-SA and its instructions, such as legislation enacted after they were 

published, go to www.irs.gov/Form1099SA.
 

Form 1099-SA

(Rev. November 2019)

Distributions 

From an HSA, 

Archer MSA, or 

Medicare Advantage 

MSA

Copy C

For 

Trustee/Payer

Department of the Treasury - Internal Revenue Service

OMB No. 1545-1517

For Privacy Act 

and Paperwork 

Reduction Act 

Notice, see the 

current General 

Instructions for 

Certain 

Information 

Returns.

For calendar year 

20

VOID CORRECTED

TRUSTEE’S/PAYER’S name, street address, city or town, state or province, 

country, ZIP or foreign postal code, and telephone number

PAYER’S TIN RECIPIENT’S TIN

RECIPIENT’S name

Street address (including apt. no.)

City or town, state or province, country, and ZIP or foreign postal code

Account number (see instructions)

1 Gross distribution

$

2 Earnings on excess cont.

$

3 Distribution code 4 FMV on date of death

$

5 HSA

Archer 

MSA

MA 

MSA

Form 1099-SA (Rev. 11-2019) www.irs.gov/Form1099SA
Instructions for Trustee/Payer

To complete Form 1099-SA, use:

• The current General Instructions for Certain Information 

Returns, and 

• The current Instructions for Forms 1099-SA and 5498-SA.

To get or to order these instructions, go to 

www.irs.gov/Form1099SA.

Filing and furnishing. For filing and furnishing instructions, 

including due dates, and to request filing or furnishing 

extensions, see the current General Instructions for Certain 

Information Returns.

To file electronically, you must have software that generates 

a file according to the specifications in Pub. 1220.

Need help? If you have questions about reporting on Form 

1099-SA, call the information reporting customer service site 

toll free at 866-455-7438 or 304-263-8700 (not toll free). 

Persons with a hearing or speech disability with access to 

TTY/TDD equipment can call 304-579-4827 (not toll free).