Contents -

Form 1099-SA

NOTE

ANY INSTRUCTIONS CONTAINED HEREIN ARE ADVISORY ONLY.

REFER TO IRS INSTRUCTIONS FOR OFFICIAL INFORMATION.



Form 1099- SA - Distributions From an HSA, Archer MSA or Medicare Advantage MSA

Distributions made from an HSA, Archer MSA or Medicare Advantage MSA (MA MSA). The distribution may have been paid directly to a medical service provider or to the account holder.  A separate return must be filed for each plan type.

Account number (Required)
Enter any number assigned by the payer to the payee that can be used by the IRS to distinguish between information returns.  This number must be unique for each information return.  The account number is critical in the correction process, especially when more than one information return is filed for a payee.  MAG-FILER will automatically assign an account number if the field is blank.

TIN # (Required)
Enter the payee's valid 9-digit Taxpayer Identification Number (SSN or EIN, as appropriate).  Leave this field blank if the TIN# is unknown.   Any form filed containing an invalid identification number in this entry may be returned for correction.

SSN  (else EIN) (Required)
Check this box if the payee TIN # is a Social Security Number (SSN) of an individual.  Leave this box blank if the payee TIN # is an Employer Identification Number (EIN) of a business or an organization.

NOTE: Imbedded blanks, extraneous words, titles, and special characters ( i.e., Mr., Mrs., Dr., period [.], apostrophe [ ' ] should be removed from Payee Name Lines.  An ampersand (&) and a dash (- ) are the only acceptable special characters.  A comma ( , ) between last name and first name that is placed by MAG-FILER is also acceptable.

Name (Required)
Enter the name of the recipient belonging to the Taxpayer Identification Number (TIN).  If the TIN, is an SSN, enter as last name suffix, first, middle initial, e.g., Doe Jr., John A.).  If the TIN is an EIN, the name is entered as is.  Use the Second Name Field if additional space is required.

Second Name Field
If the payee name requires more space than is available in the name field, ENTER ONLY THE REMAINING PORTION OF THE NAME IN THIS ENTRY.  If there are multiple payees, this field may be used for those payees' names.  DO NOT USE THIS FIELD FOR ADDRESS INFORMATION. 

Address (Required)
Enter the payee's mailing address.  The address MUST be present.  This entry must not contain any data other than the payee's mailing address.

City (Required)
Enter the payee's city.   Do not enter state and zip code information in this entry.

State (Required)
Enter the abbreviation for the payee's state or foreign country.  You must use valid U.S. Postal Service state abbreviations for U.S. addresses.

Zip (Required)
Enter the payee's valid 9-digit zip code assigned by the U.S. Postal Service.

Gross Distribution:
Enter the total amount of the distribution including any earnings on excess contributions reported in Earnings on Excess Contributions.  You are not required to determine the taxable amount of a distribution.

Earnings on Excess Contributions:
Enter the total amount of earnings distributed with any excess HSA or Archer MSA contributions returned  by the due date of the account holder's tax return.  Include this amount in Gross Distributions.  Report earnings on other distributions only in Gross Distributions.  Do not report excess MA MSA contributions returned to the Secretary of Health and Human Services or his or her representative.

Distribution Code:
Enter the appropriate distribution code: 1 - Normal distribution; 2 - Excess contributions; 3 - Disability; 4 - Death distribution other than code 6; 5 - Prohibited transaction; or 6 - Death distribution after year of death to a nonspouse beneficiary.

FMV on Date of Death:
If the account holder died, show the fair market value (FMV) of the account on the date of death.

HSA: 
Check the checkbox if the distribution was from an HSA.

Archer MSA: 
Check the checkbox if the distribution was from a Archer MSA.

MA MSA: 
Check the checkbox if the distribution was from a Medicare Advantage MSA.

Special
This area may be used to record information for state or local government reporting or for the filer's own purposes.  This information will be sent to the IRS file and does not print to the form.

Select Print
Check this box to select specific payees for printing.

Corrected Return
Check this box if this entry is a corrected return.  This is only used IF YOU HAVE ALREADY SUBMITTED MAGNETIC MEDIA FILING and wish to print or file corrected returns.  NOTE: The same account number reported on the original must also be on the corrected record.