9494 VOID CORRECTED

OMB No. 1545-1517

1 Gross distribution

TRUSTEE’S/PAYER’S name, street address, city, state, and ZIP code

Distributions

From an HSA,

Archer MSA, or

Medicare Advantage

MSA

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 Revenue Service

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 This Page

$

Copy A

For

Internal Revenue

Service Center

File with Form 1096.

For Privacy Act

and Paperwork

Reduction Act

Notice, see the 2010

General

Instructions for

Certain Information

Returns.

Archer

MSA

MA

MSA

2010
CORRECTED (if checked)

OMB No. 1545-1517

1 Gross distribution

TRUSTEE’S/PAYER’S name, street address, city, state, and ZIP code

PAYER’S federal identification number RECIPIENT’S identification number Copy B

$ $

RECIPIENT’S name

Account number (see instructions)

Form 1099-SA Department of the Treasury - Internal Revenue Service

Form 1099-SA

For

Recipient

This information

is being furnished

to the Internal

Revenue Service.

3 Distribution code

(keep for your records)

2 Earnings on excess cont.

4 FMV on date of death

Distributions

From an HSA,

Archer MSA, or

Medicare Advantage

MSA

$

5 HSA

Archer

MSA

MA

MSA

Street address (including apt. no.)

City, state, and ZIP code

2010
Instructions for Recipient 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.

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.

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

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 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.

An HSA or Archer MSA distribution is not taxable if you used it to pay

qualified medical expenses of the account holder and family 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

8889 or Form 8853). 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.

Account number. May show an account or other unique number the payer

assigned to distinguish your account.

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 Form 8889.

Recipient’s identification number. For your protection, this form may show

only the last four digits of your SSN, ITIN, or ATIN. However, the issuer has

reported your complete identification number to the IRS, and, where

applicable, to state and/or local governments.
VOID CORRECTED

OMB No. 1545-1517

1 Gross distribution

TRUSTEE’S/PAYER’S name, street address, city, state, and ZIP code

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 Revenue Service

Form 1099-SA

3 Distribution code 4 FMV on date of death

Distributions

From an HSA,

Archer MSA, or

Medicare Advantage

MSA

$

Copy C

For

Trustee/Payer

For Privacy Act

and Paperwork

Reduction Act

Notice, see the 2010

General

Instructions for

Certain Information

Returns.

5 HSA

Archer

MSA

MA

MSA

Street address (including apt. no.)

City, state, and ZIP code

2010
Instructions for Trustee/Payer

Due dates. Furnish Copy B of this form to the

recipient by January 31, 2011.

File Copy A of this form with the IRS by 

February 28, 2011. If you file electronically, the due

date is March 31, 2011. To file electronically, you must

have software that generates a file according to the

specifications in Pub. 1220, Specifications for Filing

Forms 1098, 1099, 3921, 3922, 5498, 8935, and W-2G

Electronically. IRS does not provide a fill-in form

option.

Caution: Because paper forms are scanned during

processing, you cannot file Forms 1096, 1098, 1099,

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

website.

General and specific form instructions are provided as

separate products. The products you should use to

complete Form 1099-SA are the 2010 General

Instructions for Certain Information Returns and the

2010 Instructions for Forms 1099-SA and 5498-SA. 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 the IRS website at www.irs.gov or call

1-800-TAX-FORM (1-800-829-3676). 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). For TTY/TDD equipment,

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

are Monday through Friday from 8:30 a.m. to 4:30

p.m., Eastern time.