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+Choice

MSA

PAYER’S Federal identification number RECIPIENT’S identification number 2 Earnings on excess

contributions

$ $

RECIPIENT’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (optional)

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

2004 General

Instructions for

Forms 1099, 1098,

5498, and W-2G.

2004

Archer

MSA

M+C

MSA
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

Street address (including apt. no.)

City, state, and ZIP code

Account number (optional)

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

contributions

4 FMV on date of death

Distributions

From an HSA,

Archer MSA, or

Medicare+Choice

MSA

$

2004

5 HSA

Archer

MSA

M+C

MSA
Instructions for Recipient

Note. Reference to a Medicare+Choice (M+C) MSA includes a Medicare

Advantage (MA) MSA.

Nonspouse beneficiary. If you inherited the HSA, Archer MSA, or M+C 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. In the case of an HSA, the

amount included on your tax return (other than an estate) is first reduced by

any payments from the HSA made for the decedent’s qualified medical

expenses incurred before the decedent’s death and paid within one year after

the date of death.

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. For an HSA, an excise tax of 6% for each taxable year is

imposed on you for excess individual and employer contributions that remain

in the account. See Form 5329.

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 M+C MSA

are reported to you on new Form 1099-SA. File Form 8853, Archer MSAs and

Long-Term Care Insurance Contracts, or new Form 8889, Health Savings

Accounts (HSAs), 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 M+C 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 M+C 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 M+C MSA because of

the death of your spouse, special rules apply. See 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 M+C 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, Health Savings Accounts and Other Tax-Favored

Health Plans.
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

contributions

$ $

RECIPIENT’S name

Street address (including apt. no.)

City, state, and ZIP code

Account number (optional)

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+Choice

MSA

$

Copy C

For

Payer

For Privacy Act

and Paperwork

Reduction Act

Notice, see the

2004 General

Instructions for

Forms 1099,

1098, 5498,

and W-2G.

2004

5 HSA

Archer

MSA

M+C

MSA
Instructions for Trustees/Payers

Due dates. Furnish Copy B of this form to the

recipient by January 31, 2005.

File Copy A of this form with the IRS by 

February 28, 2005. If you file electronically, the due

date is March 31, 2005.

Printed on recycled paper

Caution: Because paper forms are scanned during

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

5498 that you download and 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 2004 General

Instructions for Forms 1099, 1098, 5498, and W-2G

and the 2004 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, call 1-800-TAX-FORM

(1-800-829-3676).