1 Gross distribution

PAYER’S federal identification number RECIPIENT’S identification number 2 Earnings on excess cont.

$ $

RECIPIENT’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (see instructions)

Form 1099-SA Cat. No. 38471D Department of the Treasury - Internal R

Form 1099-SA

3 Distribution code 4 FMV on date of death

5 HSA

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

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Archer

MSA

MA

MSA
1 Gross distribution

PAYER’S federal identification number RECIPIENT’S identification number 

$ $

RECIPIENT’S name

Account number (see instructions)

Form 1099-SA Department of the Treasury - Internal R

Form 1099-SA

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3 Distribution code

(keep for your records)

2 Earnings on excess cont.

4 FMV on date of death

$

5 HSA

Archer

MSA

MA

MSA

Street address (including apt. no.)

City, state, and ZIP code
Box 2. Shows the earnings on any excess contributions you wi

HSA or Archer MSA by the due date of your income tax return. 

the excess, plus any earnings, by the due date of your income 

must include the earnings in your income in the year you receiv

distribution even if you used it to pay qualified medical expense

is included in box 1. Include the earnings on the “Other income

tax return. An excise tax of 6% for each tax year is imposed on 

individual and employer contributions that remain in the accoun

5329, Additional Taxes on Qualified Plans (Including IRAs) and 

Tax-Favored Accounts.

Box 3. These codes identify the distribution you received: 1—N

distribution; 2—Excess contributions; 3—Disability; 4—Death di

than code 6; 5—Prohibited transaction; 6—Death distribution af

death to a nonspouse beneficiary.

direct payment to the medical service provider or distributed to 

Box 4. If the account holder died, shows the FMV of the accou

of death.

Box 5. Shows the type of account that is reported on this Form 

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 is not taxable if

you used it to pay qualified medical expenses of the account holder only. If

you did not 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

did not roll it over, you must include the distribution in your income (see Form

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

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.

For more information, see the separate instructions for Form 8853 and Form

8889. Also see Pub. 969.

Nonspouse beneficiary. If you inherited the HSA, Archer MSA, or MA MSA from

someone who was not 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
1 Gross distribution

PAYER’S federal identification number RECIPIENT’S identification number 2 Earnings on excess cont.

$ $

RECIPIENT’S name

Account number (see instructions)

Form 1099-SA Department of the Treasury - Internal R

Form 1099-SA

3 Distribution code 4 FMV on date of death

$

Tr

F

a

Notice

In

Certai

5 HSA

Archer

MSA

MA

MSA

Street address (including apt. no.)

City, state, and ZIP code
Due dates. Furnish Copy B of this form to the

recipient by January 31, 2012.

specifications in Pub. 1220, Specifications fo

Forms 1097, 1098, 1099, 3921, 3922, 5498, 

W-2G Electronically. IRS does not provide a 

option.

Caution: Because paper forms are scanned during

processing, you cannot file Forms 1096, 1097, 1098,

1099, 3921, 3922, or 5498 that you print from the IRS

website.

2011 Instructions for Forms 1099SA and 5498SA. A

chart in the general instructions gives a quick guide to

which form must be filed to report a particular

payment. To order these instructions and additional

forms, visit IRS.gov or call 1-800-TAX-FORM

(1-800-829-3676). Need help? If you have questions about rep

Form 1099-SA, call the information reporting 

service site toll free at 1-866-455-7438 or

304-263-8700 (not toll free). For TTY/TDD eq

call 304-579-4827 (not toll free). The hours o

are Monday through Friday from 8:30 a.m. to 

p.m., Eastern time.