Form 1099-SA

2016

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 

2016 General 

Instructions for 

Certain 

Information 

Returns.

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 federal identification number RECIPIENT'S identification number

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 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

2016

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 Internal 

Revenue Service.

OMB No. 1545-1517

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 federal identification number RECIPIENT'S identification number

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 (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 to report a 

distribution from these accounts even if the distribution is not taxable. The payer 

is not required to compute the taxable amount of any distribution.

An HSA or Archer MSA distribution is not 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 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.

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.

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 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 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

2016

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 

2016 General 

Instructions for 

Certain 

Information 

Returns.

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 federal identification number RECIPIENT'S identification number

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 www.irs.gov/form1099sa
Instructions for Trustee/Payer

To complete Form 1099-SA, use:

• the 2016 General Instructions for Certain Information 

Returns, and 

• the 2016 Instructions for Forms 1099-SA and 5498-SA.

To order these instructions and additional forms, go to 

www.irs.gov/form1099sa.

Due dates. Furnish Copy B of this form to the recipient by 

January 31, 2017.

File Copy A of this form with the IRS by February 28, 2017. 

If you file electronically, the due date is March 31, 2017. 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 1-866-455-7438 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).