9494                      VOID                CORRECTED
TRUSTEE'S/PAYERS’ name, street address, city or town, state or province,                       OMB No. 1545-1517
country, ZIP or foreign postal code, and telephone number                                                                  Distributions 
                                                                                               Form 1099-SA                From an HSA, 
                                                                                               (Rev. November 2019)        Archer MSA, or 
                                                                                                                     Medicare Advantage 
                                                                                               For calendar year     
                                                                                                                           MSA
                                                                                                    20
PAYER’S TIN                         RECIPIENT’S TIN                      1  Gross distribution 2  Earnings on excess cont. Copy A
                                                                         $                     $                           For 
RECIPIENT’S name                                                         3  Distribution code  4  FMV on date of death     Internal Revenue 
                                                                                                                           Service Center
                                                                                                                           File with Form 1096. 
                                                                                               $                           For Privacy Act 
Street address (including apt. no.)                                      5 HSA                                             and Paperwork 
                                                                                                                           Reduction Act 
                                                                           Archer                                          Notice, see the 
                                                                           MSA
City or town, state or province, country, and ZIP or foreign postal code                                                   current General 
                                                                           MA                                              Instructions for 
                                                                           MSA
                                                                                                                           Certain 
Account number (see instructions)                                                                                          Information 
                                                                                                                           Returns.
Form  1099-SA (Rev. 11-2019)        Cat. No. 38471D            www.irs.gov/Form1099SA          Department of the Treasury - Internal Revenue Service
Do  Not  Cut  or  Separate  Forms  on  This  Page  —  Do  Not  Cut or  Separate  Forms  on  This  Page

                                                          CORRECTED (if checked)
TRUSTEE’S/PAYER’S name, street address, city or town, state or province,                          OMB No. 1545-1517
country, ZIP or foreign postal code, and telephone number                                                                     Distributions 
                                                                                                  Form 1099-SA                From an HSA, 
                                                                                                  (Rev. November 2019)        Archer MSA, or 
                                                                                                                        Medicare Advantage 
                                                                                                  For calendar year     
                                                                                                                              MSA
                                                                                                       20
PAYER’S TIN                         RECIPIENT’S TIN                      1  Gross distribution    2  Earnings on excess cont. Copy B
                                                                         $                        $                           For 
RECIPIENT’S name                                                         3  Distribution code     4  FMV on date of death     Recipient

                                                                                                  $
Street address (including apt. no.)                                      5 HSA
                                                                           Archer                                             This information 
                                                                           MSA
City or town, state or province, country, and ZIP or foreign postal code                                                      is being furnished 
                                                                           MA                                                 to the IRS.
                                                                           MSA
Account number (see instructions)

Form  1099-SA (Rev. 11-2019)        (keep for your records)                www.irs.gov/Form1099SA Department of the Treasury - Internal Revenue Service

Instructions for Recipient                                                                Nonspouse beneficiary. If you inherited the HSA, Archer MSA, or MA MSA 
                                                                                          from someone who wasnt’  your spouse, you must report as income on your  tax 
Distributions from a health savings account (HSA), Archer medical savings                 return the FMV of the account as of the date of death. Report the FMV on your 
account (MSA), or Medicare Advantage (MA) MSA are reported to you on                      tax return for the year the account owner died even if you received the 
Form 1099-SA. File Form 8853 or Form 8889 with your Form 1040 or 1040-SR                  distribution from the account in a later year. See the Instructions for Form 8853 
to report a distribution from these accounts even if the distribution isnt’taxable.       or the Instructions for Form 8889. Any earnings on the account after the date of 
The payer isnt’required to compute the taxable amount of any distribution.                death (box 1 minus box 4 of Form 1099-SA) are taxable. Include the earnings on 
An HSA or Archer MSA distribution isn’t taxable if you used it to pay qualified medical   the “Other income” line of your tax return.
expenses of the account holder or eligible family member or you rolled it over. An HSA    Account number. May show an account or other unique number the payer 
may be rolled over to another HSA; an Archer MSA may be rolled over to another Archer     assigned to distinguish your account.
MSA or an HSA. An MA MSA isn’t taxable if you used it to pay qualified medical            Box 1. Shows the amount received this year. The amount may have been a 
expenses of the account holder only. If you didn’t use the distribution from an HSA,      direct payment to the medical service provider or distributed to you.
Archer MSA, or MA MSA to pay for qualified medical expenses, or in the case of an HSA     Box 2. Shows the earnings on any excess contributions you withdrew from an HSA 
or Archer MSA, you didn’t roll it over, you must include the distribution in your income  or Archer MSA by the due date of your income tax return. If you withdrew the 
(see Form 8853 or Form 8889). Also, you may owe a penalty.                                excess, plus any earnings, by the due date of your income tax return, you must 
You may repay a mistaken distribution from an HSA no later than April 15                  include the earnings in your income in the year you received the distribution even if 
following the first year you knew or should have known the distribution was a             you used it to pay qualified medical expenses. This amount is included in box 1. 
mistake, providing the trustee allows the repayment.                                      Include the earnings on the “Other income” line of your tax return. An excise tax of 
For more information, see the Instructions for Form 8853 and the Instructions             6% for each tax year is imposed on you for excess individual and employer 
for Form 8889. Also see Pub. 969.                                                         contributions that remain in the account. See Form 5329, Additional Taxes on 
Recipient’s taxpayer identification number (TIN). For your protection, this form          Qualified Plans (Including IRAs) and Other Tax-Favored Accounts.
may show only the last four digits of your TIN (SSN, ITIN, ATIN, or EIN). However,        Box 3. These codes identify the distribution you received: 1—Normal 
the issuer has reported your complete identification number to the IRS.                   distribution; 2—Excess contributions; 3—Disability; 4—Death distribution other 
Spouse beneficiary. If you inherited an Archer MSA or MA MSA because of the death of      than code 6; 5—Prohibited transaction; 6—Death distribution after year of death 
your spouse, special rules apply. See the Instructions for Form 8853. If you inherited an to a nonspouse beneficiary.
HSA because of the death of your spouse, see the Instructions for Form 8889.              Box 4. If the account holder died, shows the FMV of the account on the date of death.
Estate beneficiary. If the HSA, Archer MSA, or MA MSA account holder dies                 Box 5. Shows the type of account that is reported on this Form 1099-SA.
and the estate is the beneficiary, the fair market value (FMV) of the account on          Future developments. For the latest information about developments related to 
the date of death is includible in the account holder’s gross income. Report the          Form 1099-SA and its instructions, such as legislation enacted after they were 
amount on the account holder’s final income tax return.                                   published, go to www.irs.gov/Form1099SA.

                                    VOID                  CORRECTED
TRUSTEE’S/PAYER’S name, street address, city or town, state or province,                       OMB No. 1545-1517
country, ZIP or foreign postal code, and telephone number                                                                  Distributions 
                                                                                               Form 1099-SA                From an HSA, 
                                                                                                                           Archer MSA, or 
                                                                                               (Rev. November 2019)  Medicare Advantage 
                                                                                               For calendar year     
                                                                                                                           MSA
                                                                                                    20
PAYER’S TIN                         RECIPIENT’S TIN                      1  Gross distribution 2  Earnings on excess cont. Copy C
                                                                         $                     $                           For 
RECIPIENT’S name                                                         3  Distribution code  4  FMV on date of death     Trustee/Payer
                                                                                                                           For Privacy Act 
                                                                                               $                           and Paperwork 
Street address (including apt. no.)                                      5 HSA                                             Reduction Act 
                                                                           Archer                                          Notice, see the 
                                                                           MSA                                             current General 
City or town, state or province, country, and ZIP or foreign postal code                                                   Instructions for 
                                                                           MA 
                                                                           MSA                                             Certain 
Account number (see instructions)                                                                                          Information 
                                                                                                                           Returns.
Form  1099-SA (Rev. 11-2019)                              www.irs.gov/Form1099SA               Department of the Treasury - Internal Revenue Service

Instructions for Trustee/Payer
To complete Form 1099-SA, use:                                  To file electronically, you must have software that generates 
• The current General Instructions for Certain Information      a file according to the specifications in Pub. 1220.
Returns, and                                                    Need help? If you have questions about reporting on Form 
• The current Instructions for Forms 1099-SA and 5498-SA.       1099-SA, call the information reporting customer service site 
                                                                toll free at 866-455-7438 or 304-263-8700 (not toll free). 
To get or to order these instructions, go to                    Persons with a hearing or speech disability with access to 
www.irs.gov/Form1099SA.                                         TTY/TDD equipment can call 304-579-4827 (not toll free). 
Filing and furnishing. For filing and furnishing instructions, 
including due dates, and to request filing or furnishing 
extensions, see the current General Instructions for Certain 
Information Returns.