Form 1099-SA

2012

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 

2012 General 

Instructions for 

Certain 

Information 

Returns.

9494 VOID CORRECTED

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

PAYER'S federal identification number RECIPIENT'S identification number

RECIPIENT'S name

Street address (including apt. no.)

City, state, and ZIP 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

Do Not Cut or Separate Forms on This Page — Do Not Cut or Separate Forms on This Page
Form 1099-SA

2012

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, state, and ZIP code

PAYER'S federal identification number RECIPIENT'S identification number

RECIPIENT'S name

Street address (including apt. no.)

City, state, and ZIP 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)
Instructions for Recipient

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.

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 8853 or Form 

8889). Also, you may owe a penalty.

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

8889. Also see Pub. 969.

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

only the last four digits of your social security number (SSN), individual taxpayer 

identification number (ITIN), or adoption taxpayer identification number (ATIN). 

However, the issuer has reported your complete identification number to the 

IRS, and, where applicable, to state and/or local governments.

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 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 TaxFavored 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.
Form 1099-SA

2012

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 

2012 General 

Instructions for 

Certain 

Information 

Returns.

VOID CORRECTED

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

PAYER'S federal identification number RECIPIENT'S identification number

RECIPIENT'S name

Street address (including apt. no.)

City, state, and ZIP 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
Instructions for Trustee/Payer

General and specific form instructions are provided as 

separate products. The products you should use to 

complete Form 1099-SA are the 2012 General 

Instructions for Certain Information Returns and the 

2012 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 

IRS.gov or call 1-800-TAX-FORM (1-800-829-3676).

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.

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

by January 31, 2013.

File Copy A of this form with the IRS by 

February 28, 2013. If you file electronically, the due date 

is April 1, 2013. To file electronically, you must have 

software that generates a file according to the 

specifications in Pub. 1220, Specifications for Filing 

Forms 1097, 1098, 1099, 3921, 3922, 5498, 8935, and 

W-2G Electronically. IRS does not provide a fill-in form 

option.

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.